THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

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GIFT  OF 

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COUNTY  MEDICAL  SOCIETY 


41 


SURGERY 

OF  THE 

BLOOD  VESSELS 


sea- 


T 


IURGEEY 

OF  THE 

BLOOD  VESSELS 


BY 

J.  SHELTONiHORSLEY,  M.  D,  F.  A.  C.  S. 

SURGEON-IN-CHARGE   OF   ST.   ELIZABETH'S   HOSPITAL,   RICHMOND,   VA.;    A 

FOUNDER  AND  FELLOW  OF  THE  AMERICAN  COLLEGE  OF  SURGEONS; 

EX-PRESIDENT  OF  THE  RICHMOND  ACADEMY  OF  MEDICINE 

AND  SURGERY;  MEMBER  OF  SOUTHERN  SURGICAL 

AND  GYNECOLOGICAL  ASSOCIATION,  ETC. 


ILLUSTRATED 


ST.  LOUIS 

0.  V.  MOSBY  COMPANY 

1915 


COPYRIGHT,  1915,  BY  C.  V.  MOSBY  COMPANY 


Press  of 

C.  V.  Mosbu  Company 
St.  Louis 


edicsi 
rsrv 

WC- 


TO 

MY  WIFE 


THIS  VOLUME  IS  AFFECTIONATELY 
DEDICATED 


Is 


593015 


PREFACE. 

To  no  department  of  surgical  endeavor  have  Ameri- 
cans contributed  so  largely  in  recent  years  as  to  blood- 
vessel surgery.  The  first  successful  end-to-end  suturing 
of  a  divided  artery  in  man  was  done  by  Murphy,  of 
Chicago,  in  1897,  when  he  united  the  femoral  by  his  in- 
vagination  method.  The  revolutionizing  treatment  of 
aneurisms  by  Matas,  who  devised  endo-aneurismorrha- 
phy,  is  considered  the  most  important  advance  in  the 
therapy  of  this  disease  since  the  days  of  Hunter.  The 
development  of  transfusion  of  blood  by  Crile,  of  Cleve- 
land, is  another  notable  instance  of  the  large  share 
Americans  have  had  in  the  progress  of  blood-vessel  sur- 
gery. Halsted,  of  Johns  Hopkins,  introduced  the  prin- 
ciple of  partial  or  gradual  occlusion  of  an  artery  by 
means  of  malleable  metallic  bands.  Finally,  Carrel,  an 
American  by  adoption,  and  his  former  associate,  C.  C. 
Guthrie,  have  carefully  worked  out  the  technique  of  blood- 
vessel suturing  and  were  the  first  to  place  it  on  a  stable 
basis.  A  monograph  dealing  with  the  various  phases  of 
blood-vessel  surgery,  and  particularly  with  its  recent 
developments,  may  prove  of  some  interest  in  a  country 
that  has  contributed  so  largely  to  its  progress. 

It  has  been  the  aim  of  the  author  to  present  the 
scientific  and  the  laboratory  features  of  vascular  surgery 
and  particularly  its  practical  aspects  that  may  be  of  in- 
terest both  to  the  surgeon  and  to  the  general  practitioner. 
Therefore  the  treatment  of  hemorrhage,  pathologic  and 
traumatic,  and  such  subjects  as  aneurisms,  thrombosis 
and  embolism,  congenital  nevi,  varicose  veins,  and  hem- 

7 


8  PREFACE. 

orrhoids  are  described  as  well  as  the  history  and  tech- 
nique of  suturing  blood-vessels  and  transfusion  of  blood. 

Probably  the  most  interesting  surgical  reading  is  an 
account  of  personal  experience  and  original  research. 
Whether  the  reader  approves  of  the  work  or  not,  it  may 
at  least  present  the  subject  in  a  new  light.  It  is  for  this 
reason  that  a  good  portion  of  the  book  is  taken  up  with 
the  original  work  of  the  author,  who  is  fully  aware  that 
the  importance  of  what  he  has  done  is  not  in  proportion 
to  the  space  it  occupies.  His  methods  of  end-to-end 
suture  of  blood-vessels,  of  transfusion  of  blood,  of  lateral 
suture  of  blood-vessels,  of  suturing  arteriovenous  aneu- 
risms, of  making  an  Eck  fistula,  of  transplantation  of  the 
anterior  temporal  artery,  and  of  resection  or  transplan- 
tation of  intestine  after  embolism  of  the  mesenteric  arter- 
ies are  therefore  described  in  considerable  detail. 

It  is  a  most  pleasant  duty  to  return  thanks  to  the  sur- 
geons who  have  invited  the  author  to  demonstrate  his 
method  of  suturing  blood-vessels  at  their  clinics,  or  in 
their  laboratories.  Among  them  are  Dr.  Donald  Bal- 
four,  of  the  Mayo  Clinic,  at  whose  invitation  the  author 
performed  a  transfusion  of  blood;  Dr.  A.  A.  Law,  a 
similar  operation  being  done  at  his  request  at  the  Uni- 
versity of  Minnesota  Hospital;  Dr.  W.  L.  Rodman,  by 
whose  courtesy  the  author  lectured  on  blood-vessel  sur- 
gery and  demonstrated  his  method  of  suturing  blood- 
vessels at  the  Medico-Chirurgical  College,  of  Philadel- 
phia; Dr.  A.  D.  Bevan,  who  kindly  arranged  for  a 
demonstration  of  this  technique  on  animals  at  the  Eush 
Medical  College;  Dr.  J.  Frank  Corbett,  at  whose  invita- 
tion the  technique  was  demonstrated  on  animals  in  the 
laboratory  of  experimental  surgery  at  the  University  of 
Minnesota;  and  Dr.  H.  A.  RojTster,  by  whom  the  author 
was  invited  to  demonstrate  his  method  of  suturing  blood- 


PREFACE.  9 

vessels  on  animals  at  Raleigh,  North  Carolina,  before  the 
medical  society  of  which  Dr.  Eoyster  was  president, 
There  are  many  others  whose  suggestions  and  words  of 
encouragement  are  deeply  appreciated. 

Naturally,  many  books  and  journals  have  been  con- 
sulted in  preparing  this  book.  In  the  chapters  on  the 
history  of  blood-vessel  surgery  and  of  transfusion  an 
effort  has  been  made  to  follow  the  chronologic  order  and 
references  have  been  given  only  when  the  literature  was 
quite  recent  or  where  for  some  other  reason  it  seemed  ad- 
visable. The  author  feels  particularly  indebted  to  the 
section  by  Matas,  in  "Keen's  Surgery,"  on  aneurisms, 
which  has  been  freely  drawn  from;  to  Crile's  work, 
"Hemorrhage  and  Transfusion";  to  Warren's  "Healing 
of  Arteries";  to  the  monographs  on  blood-vessel  surgery 
by  Guthrie  and  by  Bernheim,  and  to  various  papers  by 
Stephen  H.  Watts. 

To  Miss  Helen  L.  Lorraine,  the  artist,  a  pupil  of  Mr. 
Max  Brodel,  the  author  is  greatly  indebted  for  her  ex- 
cellent drawings. 

The  publishers,  The  C.  V.  Mosby  Company,  at  whose 
suggestion  this  book  was  written,  have  extended  many 
courtesies  that  are  deeply  appreciated. 

J.  S.  II. 

January,  1915. 


CONTENTS. 


CHAPTER  I. 
THE  STRUCTURE  AND  HISTOLOGIC  REPAIR  OF  BLOOD-VESSELS  . 

CHAPTER  II. 
THE  INDICATIONS   FOR  BLOOD-VESSEL   SUTURING    .......     2!) 

CHAPTER  III. 
HISTORY  OF  BLOOD-VESSEL  SURGERY        ..........     31 


CHAPTER  IV. 
THE  TECHNIQUE  OF  SUTURING  BLOOD-VESSELS  ........     46 

CHAPTER  V. 

LATERAL    ANASTOMOSIS    OF    BLOOD-VESSELS,    AND    REVERSAL    OF    THE 
CIRCULATION       ................     80 

CHAPTER  VI. 
TRANSFUSION  OF  BLOOD  95 


CHAPTER  VII. 
TRANSFUSION   OF   BLOOD    (Continued)     .... 

CHAPTER  VIII. 
HEMORRHAGE 135 

CHAPTER  IX. 
PATHOLOGIC  HEMORRHAGE 1(19 

CHAPTER  X. 
THROMBOSIS  AND  EMBOLISM ITti 

CHAPTER  XT. 

TREATMENT  OF  OCCLUSION  OF  THE  MESENTERIC  BLOOD-VESSELS;  RESEC- 
TION AND  TRANSPLANTATION   OF  INTESTINE 203 

CHAPTER  XII. 
ANEURISMS 211 

CHAPTER  XIII. 

ARTEBIOVENOUS  ANEUBISMS 245 

11 


12  CONTENTS. 

CHAPTER  XIV.  PAGE 

TUMORS  OF  THE  BLOOD-VESSELS 255 

CHAPTER  XV. 
VARICES;    VARICOSE   VEINS,   VARICOCELE,   AND   HEMORRHOIDS    .      .      .   264 

CHAPTER  XVI. 
TRANSPLANTATION  OF  THE  ANTERIOR  TEMPORAL  ARTERY      ....   286 

INDEX  .  .   297 


ILLUSTRATIONS 


PAGE 

Fig.     1.     Endothelium  of  arteriole  after  silver   staining    ....  IS 

Fig.     2.     Endothelial  cells  more  highly  magnified 18 

Fig.     3.     Drawing  of  transverse  section  of  aorta 19 

Fig.     4.     Drawing  of  transverse  section  of  artery  of  medium  si/.e      .  21 

Fig.     5.     Drawing  of  transverse  section  of  vein  of  medium  size     .      .  23 
Fig.     6.     Microphotograph    of    carotid    artery    of    dog,    divided    and 

sutured,  and  the  specimen  removed  eleven  days  afterwards   .      .  24 
Fig.     7.     Microphotograph    of    carotid    artery    of    dog,    divided    and 

sutured,  and  the  specimen  removed  173  days  afterwards   ...  25 
Fig.     8.     Microphotograph   of   union   of   artery   and  vein   sixty-three 

days  after  operation 26 

Fig.     9.     Payr's  magnesium  tubes  and  discs  for  uniting  arteries     .  35 

Fig.   10.     Carrel's  method  of  end-to-end  suture  of  arteries  ....  38 

Fig.  11.     Dorrance's   method   of   suturing  arteries 41 

Fig.  12.     Bickham's  methods  of  applying  mattress  sutures  in  wounds 

of   arteries 43 

Fig.  13.     The  lumen  of  a  blood-vessel  after  different  methods  of  sutur- 
ing      49 

Fig.  14.     Arterial  suture  staff 51 

Fig.  15.     Special   instruments  used  in  end-to-end  suturing  of   blood- 
vessels      53 

Fig.  16.     Suturing  of  blood-vessels.     Exposing  the  artery  ....  54 

Fig.  17.     Suturing  of  blood-vessels.     Removing  adventitia        ...  55 
Fig.  18.     Suturing    of    blood-vessels.     Anointing    the    collapsed    end 

with  vaseline 56 

Fig.  19.     Suturing  of  blood-vessels.     Fastening  the  first  guy  suture 

to  the  suture  staff 57 

Fig.  20.     Suturing  of  blood-vessels.     Inserting  the  second  guy  suture  58 
Fig.  21.     Suturing  of  blood-vessels.     Position   for   placing  the  third 

guy   suture 59 

Fig.  22.     Suturing  of  blood-vessels.     Position  for  fastening  the  third 

guy  suture  to  the  staff 60 

Fig.  23.     Suturing  of  blood-vessels.     All  guy  sutures  in  place    .      .  61 
Fig.  24.     Suturing   of   blood-vessels.     Suturing   first   third   of   blood- 
vessel wound 62 

Fig.  25.     Suturing  of  blood-vessels.     Suturing  second  third    ...  63 
Fig.  26.     Suturing  of  blood-vessels.     Suturing  last  third   ....  64 
Fig.  27.     Suturing  of  blood-vessels.     The  suturing  completed.     Test- 
ing for  leakage      .      .    ' 66 

13 


14  ILLUSTRATIONS. 

PAGE 

Fig.  28.     Suturing  a  rubber  tube  into  defect  caused  by  removal  of  a 

segment  of  an  artery 72 

Fig.  29.     External  view  of  iliac  artery  of  dog  after  being  sutured   .  73 

Fig.  30.     Lumen  of  carotid  artery  of   dog  after  being  sutured    .      .  73 

Fig.  31.     Transplanted  segment  of  the  external  jugular  vein   ...  74 

Fig.  32.     Specimen  of  reversal  of  circulation  in  the  neck   ....  75 
Fig.  33.     Specimen  of  excision  of  a  segment  of  the  abdominal  aorta 

with  rubber  tube  sutured  into  defect 76 

Fig.  34.     Photograph  of  dog  six  months  after  excision  of  portion  of 

the  abdominal  aorta 77 

Fig.  35.     Forceps  for   lateral  blood-vessel   suturing    ....          .85 

Fig.  36.     Forceps  grasping  blood-vessel 87 

Fig.  37.     Removing  adventitia  before  lateral  anastomosis   ....  87 

Fig.  38.     Method  of  incising  blood-vessels  in  creating  an  Eck  fistula  88 
Fig.  39.     Method   of   incising   blood-vessels    in    lateral    arteriovenous 

anastomosis 89 

Fig.  40.     Appearance  of  blood-vessel  and  position  of  traction  suture 

just  before  beginning  the  suturing  in  lateral  anastomosis  ...  89 
Fig.  41.     First   stage   of   suturing   in   lateral   anastomosis   of   blood- 
vessels      90 

Fig.  42.     Suturing  last  half  of  lateral  anastomosis 91 

Fig.  43.     Lateral  anastomosis  of  blood-vessels  completed    ....  92 

Fig.  44.     Specimen  of  Eck  fistula  from  a  dog 92 

Fig.  45.     Specimen  of  arteriovenous  anastomosis  from  a  dog  ...  93 

Fig.  46.     Crile's  method  of  transfusing  blood 101 

fig.  47.     Brewer's  tubes  for  transfusion 103 

Fig.  48.     Bernheim's  tube  for   transfusion 105 

Fig.  49.     Bryan's  cannula  for  transfusion 106 

Fig.  50.     Elsberg's    cannula    for    transfusion 106 

Fig.  51.     Curtis  and  David's  apparatus  for   transfusion    ....  108 
Fig.  52.     Kimpton  and  Brown's  apparatus  for  transfusion      .      .      .  110 
Fig.  53.     Kimpton  and  Brown's   apparatus   for   transfusion   in   hori- 
zontal position 110 

Fig.  54.     Landon's  cannula   for  transfusion 112 

Fig.  55.     Method   of   using  Landon's   cannula 112 

Fig.  56.     McGrath's  forceps  for  transfusion 114 

Fig.  57.     Horsley's  method  of  transfusion  by  suturing 118 

Fig.  58.     Method  of  compressing  the  carotid  artery 140 

Fig.  59.     Method  of  compressing  the  subclavian  artery      ....  141 

Fig.  60.     Method  of  compressing  the  brachial  artery 142 

Fig.  61.     Method  of  compressing  the  femoral  artery 143 

Fig.  62.     Incision    for    approaching    the    heart    and    the    pulmonary 

artery 197 

Fig.  63.     Trendelenburg's   instruments   for    operation    on    pulmonary 

embolus 198 

Fig.  64.     Trendelenburg's    operation    for    pulmonary    embolism.     Re- 
moving the  embolus 199 


ILLUSTKATIONS.  15 

PAGE 

Fig.  65.     Closing  the  wound  in  the  pulmonary  artery  after  removing 

the   embolus 201 

Fig.  66.     Horsley's  method  of  resecting  the  bowel;  first  stage       .      .  2o.~> 
Fig.  67.     Horsley's  method  of  resecting  the  bowel;   second  stage        .  20li 
Fig.  68.     Horsley's  method  of  resecting  the  bowel;   third  stage    .      .  207 
Fig.  69.     Horsley's   method   of   resecting   the   bowel;    operation    com- 
pleted        208 

Fig.  70.     Transplantation   of   the   ileum   after   extensive   resection    of 

the    sigmoid 20!) 

Fig.  71.     Classical  methods  of  applying  the  ligature  for  aneurism    .  227 

Fig.  72.     Matas'  operation  of  endo-aneurismorrhaphy 231 

Fig.  73.     Operation  for  arteriovenous  aneurism  by  means  of  clamps 

for  lateral  suturing 2.~>1 

Fig.  74.     Second  stage  of  operation  for  arteriovenous  aneurism   .      .  2f>2 

Fig.  75.     Photograph  of  a  boy  with  angioma  of  nose 2til 

Fig.  76.     Another  view  of  above  boy 201 

Fig.  77.     Photograph    showing    results    of    hot    water    injection    in 

angioma  of  nose 2(il 

Fig.  78.     Mayo's  operation  for  varicose  veins 26!) 

Fig.  79.     Clamp  and  cautery  operation  for  hemorrhoids       ....  2S2 
Fig.  80.     Method  of  inserting  tube  before  removing  forceps  in  clamp 

and  cautery  operation  for  hemorrhoids 283 

Fig.  81.     Transplantation  of  anterior  temporal  artery;  first  stage     .  288 

Fig.  82.     Transplantation  of  anterior  temporal  artery;  second  stage  .  28!) 

Fig.  83.     Transplantation  of  anterior  temporal  artery ;  third  stage;   .  290 
Fig.  84.     Transplantation    of    anterior    temporal    artery;     operation 

completed 291 

Fig.  85.     Photograph  of  patient  with  extensive  defect  in  the  cheek    .  293 
Fig.  86.     Photograph   of   same   patient   after   transplantation    of   an- 
terior temporal  artery  with  frontal  flap 293 

Fig.  87.     Photograph  of  patient  after  removal  of  recurrent  cancer  of 

cheek 294 

Fig.  88.     Photograph   of   same   patient   after   transplantation   of   an- 
terior temporal  artery  with  frontal  flap 29.~> 

Fig.  89.     Photograph  of  patient  shown  in  Figs.  87  and  88,  showing 

absence  of  any  facial  paralysis 295 


SURGERY  OF  THE  BLOOD- 
VESSELS 

CHAPTER  I. 

THE   STRUCTURE  AND  HISTOLOGIC   REPAIR 
OF  BLOOD-VESSELS. 

A  knowledge  of  the  histology  of  blood-vessels  is  neces- 
sary for  a  proper  appreciation  of  the  healing  of  blood- 
vessels. Blood-vessels  are  described  as  having  three 
coats:  an  inner,  or  tunica  intima;  a  middle,  or  tunica 
media;  and  an  external,  or  tunica  externa,  or,  as  it  is 
usually  called,  adventitia.  While  these  coats  are  to  a 
greater  or  less  extent  present  in  most  blood-vessels,  their 
arrangement  and  their  relative  proportion  vary  very 
greatly.  The  tunica  intima  consists  of  vascular  endo- 
thelium,  which  is  supported  by  a  variable  amount  of  fibro- 
elastic  tissue,  the  elastic  tissue  predominating.  The 
capillaries  consist  practically  entirely  of  the  tunica  in- 
tima, which  in  this  instance  amounts  to  but  little  more 
than  the  endothelial  lining.  The  middle  coat,  or  tunica 
media,  is  a  mixture  of  smooth  muscle,  elastic  tissue,  and 
fibrous  tissue ;  while  the  adventitia,  which  is  very  strong 
but  generally  thinner  than  the  middle  coat,  consists  of 
fibro-elastic  tissue.  The  essential  coat  of  the  blood-ves- 
sel is  the  inner  coat,  or  tunica  intima.1 

In  arteries  the  endothelium  of  the  intima  is  made  up 
of  flat,  spindle-shaped  cells  joined  together  irregularly  by 

i  Piersol :    Human   Anatomy,   Vol.   I. 

17 


18 


SURGERY    OF    THE    BLOOD-VESSELS. 


a  kind  of  cement  substance  that  is  shown  by  silver  stain- 
ing. Where  these  cells  come  together  there  are  occasion- 
ally stigmata  or  points  where  the  junction  of  the  cell  is 
less  accurate  than  usual.  The  sharp  outlines  of  the  en- 
dothelial  cells  are  less  marked  in  capillaries  than  in  larger 
vessels.  A  small  oval  nucleus  in  the  endothelial  cells  can 
be  demonstrated  (Figs.  1  and  2). 


Fig.   1. 


Fig.   2. 


Fig.    1. — Endothelium  of  arteriole  after  silver  staining,      x  200.       (After  Piersol.) 
Fig.   2. — Endothelial   cells   more   highly   magnified,      x    500.       (After    Piersol.) 

The  involuntary  or  smooth  muscle  varies  greatly  in 
amount.  It  may  form  a  thin  or  imperfect  layer  in  the 
arterioles,  or  a  thick  coat  in  the  larger  arteries.  It  is 
most  abundant  in  arteries  of  medium  size,  where  it  is 
found  in  broad  bundles  between  fibers  of  elastic  tissue. 
In  veins  there  is  but  little  muscle  and  sometimes  it  is  en- 
tirely wanting. 

Connective  tissue  occurs  as  fibrous  and  elastic  tissue. 
Elastic  tissue  is  very  conspicuous  in  all  of  the  arteries 
except  the  smallest  and  is  found  to  a  considerable  extent 
in  veins.  It  is  very  abundant  in  the  larger  arteries  and, 


STRUCTURE    AND    HISTOLOGY    OF    BLOOD-YKSSKLS.  19 


Intimu 


Media 


Adventitia 


Fig.   3. — Drawing  of  transverse  section   of   aorta,     x    120.      (Original.) 


20  SURGERY    OF    THE    BLOOD-VESSELS. 

as  has  already  been  mentioned,  forms  a  basement  mem- 
brane for  the  endothelium  of  the  intima  (Fig.  3). 

All  of  the  larger  vessels  are  provided  with  minute  nu- 
trient vessels  which  usually  come  from  some  neighboring 
artery  and  are  distributed  in  the  adventitia  of  the  blood- 
vessel. They  are  called  vasa  vasormn.  Lymphatics  and 
nerves  are  also  found  in  the  outer  coats  of  the  blood- 
vessels. The  plexus  of  nerves  that  surrounds  arteries 
is  particularly  abundant.  Small  nerve  fibers  from  this 
plexus  enter  the  media  and  are  distributed  among  the 
muscle  cells.  These  nerve  fibers  are  chiefly  motor  in 
function  and  are  a  part  of  the  great  vasomotor  system. 
Sensory  nerves  undoubtedly  occur  quite  constantly  ac- 
companying the  vessel  wall.  This  is  frequently  demon- 
strated in  operations  under  a  local  anesthetic  when  the 
clamping  of  a  blood-vessel  will  cause  pain  even  though 
the  surrounding  tissue  appears  to  be  free  from  sensation. 

In  an  artery  of  medium  size,  about  half  a  centimeter 
in  diameter,  the  intima  is  seen  in  section  as  distinctly 
corrugated,  which  is  due  to  the  fact  that  the  vessel  is 
collapsed  and  the  internal  elastic  membrane  draws  the 
endothelial  lining  into  folds.  Under  normal  pressure 
when  the  artery  is  functionating  these  wrinkles  would  be 
smoothed  out.  The  intima  in  such  an  artery  consists  of 
a  layer  of  endothelium  that  rests  on  a  thin  layer  of 
fibrous  and  elastic  tissue  and  this  upon  the  elastic  mem- 
brane, the  total  thickness  being  very  small  in  proportion 
to  the  thickness  of  the  other  coats.  The  tunica  media,  or 
middle  coat,  is  quite  thick  and  comprises  more  than  one- 
half  of  the  total  thickness  of  an  artery  of  medium  size. 
It  consists  of  smooth  muscle  and  elastic  and  fibrous  tis- 
sue. The  external  layer  of  the  middle  coat  is  an  elastic 
membrane  called  the  external  elastic  membrane,  which  is 
similar  in  construction  to  the  internal  elastic  membrane 


STRUCTURE    AND    HISTOLOGY    OF    BLOOD-VESSELS.  21 


Intima 


Media 


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>M^\N  S  ,,^  ^  -^  >CS^  i>f^  ^^"    Internal 


^^f^r^ 

"•*--* ''^i—     'j^^'^^^^''''-^-^   "<*.  * 

•^^"^^^^^^  .S^-  5^^  v"^™v*^  ^^  "^Li-"^  ':i- 


Adventitia 


r^'^r    >»^  *ti^'--.s^-  --.-^ 


-  External 
elastic 
membrane 


Fig.   4. — Drawing  of   transverse   section   of   an    artery   of   medium   size,      x    120. 

(Original.) 


22  SURGERY    OF    THE    BLOOD-VESSELS. 

of  the  intima.  The  adventitia  is  thinner  than  the  media 
but  is  exceedingly  strong.  It  is  a  mixture  of  fibrous  and 
elastic  tissue  and  contains  the  vasa  vasorum,  lymph  chan- 
nels, and  the  plexus  of  nerves.  As  the  artery  decreases 
in  size,  all  the  coats  except  the  intima  diminish.  The 
internal  elastic  membrane  disappears  first,  then  the  me- 
dia. Just  before  the  vessel  becomes  a  capillary  the  mea- 
ger amount  of  muscle  cells  disappears.  In  capillaries 
practically  nothing  is  left  except  the  endothelial  lining 
with  a  small  support  of  connective  tissue.2 

As  an  artery  of  medium  size  becomes  larger,  the  intima 
and  media  increase  in  bulk  and  the  boundary  between 
these  two  coats  becomes  less  marked,  for  the  elastic  tis- 
sue is  a  more  prominent  feature  of  the  middle  coat  which 
gradually  blends  with  the  internal  elastic  membrane. 
The  muscular  tissue  in  the  media  is  largely  replaced  in 
large  arteries  by  fibro-elastic  tissue.  The  adventitia  is 
somewhat  increased  and  consists  of  fibro-elastic  tissue 
as  in  smaller  arteries  (Fig.  4).  It  is  exceedingly  strong. 
Near  the  heart  some  muscle  cells  resembling  cardiac  mus- 
cle may  run  up  for  a  short  distance  into  the  aorta  or  pul- 
monary artery. 

Veins  are  always  thinner  than  arteries  and  contain  less 
muscular  and  elastic  tissue.  In  a  vein  of  medium  size 
(Fig.  5)  the  intima  is  of  somewhat  the  same  construction 
as  in  an  artery  of  similar  size,  except  that  the  endothelial 
cells  are  broad  and  short  instead  of  being  long  and  spin- 
dle-shaped as  in  an  artery  and  the  layer  of  elastic  and 
connective  tissue  is  much  thinner  than  in  an  artery.  The 
internal  elastic  membrane  of  an  artery  of  medium  size  is 
practically  lacking  in  a  vein  of  similar  caliber.  In  the 
tunica  media,  muscular  tissue  is  scanty.  The  media  is 
altogether  much  thinner  than  in  the  artery  and  is  dis- 

zPiersol:    Human   Anatomy,   Vol.   I. 


STRUCTURE    AND    HISTOLOGY    OF    BLOOD-VESSELS.  2.6 

tinctly  deficient  in  muscle  cells  as  compared  with  an  ar- 
tery. The  adventitia  of  a  vein  is  frequently  thicker  than 
the  media  and  is  of  similar  construction  to  the  adventitia 
of  an  artery.  In  the  lower  extremities  the  veins  often 
contain  muscle  cells  arranged  longitudinally. 

The  valves  of  the  veins  consist  of  pairs  of  crescent- 
shaped  folds  of  intima.  They  form  pockets  that  look 
toward  the  direction  of  the  blood  current  in  the  vein,  and 


Intima 
Media 


Adventitia 


Fig.    5. — Drawing   of   transverse   section   of   a   vein    of   medium   size,      x    120. 

(Original.) 

when  filled  the  sides  of  the  valves  come  together  and  pre- 
vent the  reflux  of  blood. 

In  large  veins  the  media  is  chiefly  increased  by  the  ap- 
pearance of  more  elastic  and  fibrous  tissue,  though  in  the 
splenic  and  portal  veins  much  muscular  tissue  is  in  the 
media.  In  the  larger  veins  the  adventitia  is  markedly 
increased  and  often,  as  in  the  vena  cava,  contains  longi- 
tudinal bundles  of  smooth  muscle. 

The  small  veins  have  only  endothelium  and  connective 
tissue.  Approaching  the  capillaries,  the  connective  tis- 
sue decreases,  leaving  the  endothelium  alone. 

The  capillaries  consist  of  an  endothelial  coat  with  thin 
walls  that  favor  the  passage  of  the  blood  plasma  into  the 


24 


SURGERY    OF    THE    BLOOD-VESSELS. 


surrounding  tissue.  The  endothelial  cells  are  elongated 
cells  with  oval  nuclei.  Stomata  do  not  occur  in  the  walls 
of  the  capillary.  Blood  cells  gain  exit  between  the  endo- 
thelial cells.  In  capillaries  of  the  choroid,  liver,  and  the 


Fig.  6. — The  carotid  artery  of  a  dog  which  was  divided  and  sutured  and  the  speci- 
men removed  eleven  days  afterwards.  Note  the  silk  which  on  the  surface  is 
completely  buried  by  a  thin  layer  of  endothelium.  Magnification,  65  diameters. 

glomeruli  of  the  kidney  the  endothelial  lining  seems  to 
be  continuous  as  a  kind  of  syncytial  layer.3 

The  healing  of  blood-vessels  after  ligation  has  been  a 
subject  of  study  by  surgical  pathologists  for  many  years 

3  Piersol:    Human   Anatomy,   Vol.   I. 


STRUCTURE    AND    HISTOLOGY    OF    BLOOD-VESSELS.  -!.) 

and  the  literature  on  this  subject  is  abundant.  Healing 
by  the  so-called  organization  of  a  thrombus,  accom- 
panying injured  intima,  and  by  a  mere  approximation 
of  the  intima  has  been  investigated  experimentally  and 


m 


Fig.  7. — Microphotograph  of  a  carotid  artery  of  a  dog  which  was  divided  and 
sutured  and  the  specimen  removed  173  days  after  operation.  Note  the  par- 
tial regeneration  of  the  coats  of  the  vessel  and  the  well  covered  silk.  Mag- 
nification, 85  diameters. 

clinically  in  many  works  and  has  been  studied  with 
particular  care  by  J.  Collins  Warren  in  a  monograph, 
"The  Healing  of  Arteries,"  published  in  1886.  The 
healing  of  arteries,  however,  of  chief  interest  in  mod- 
ern vascular  surgery  is  that  which  follows  suturing  and 


26 


SURGERY    OF    THE    BLOOD-VESSELS. 


not  the  ligature.  In  successful  arterial  suturing  repair 
in  the  course  of  time  is  complete.  The  accompanying 
microphotographs  show  that  the  suture  material  is  cov- 
ered with  endothelial  lining  and  the  middle  and  outer 


Fig.  8. — Microphotograph  of  union  of  artery  and  vein  sixty-three  days  after  opera- 
tion. The  section  was  somewhat  torn  in  cutting  hut  the  silk  can  be  easily 
seen  covered  with  a  layer  of  endothelium.  Magnification  57  diameters. 

coats  have  begun  to  regenerate  even  a  few  weeks  after 
the  suturing  (Figs.  6,  7  and  8).  In  older  specimens 
studied  by  other  experimenters  the  repair  is  complete. 
Matas  4  says  that  repair  which  follows  a  properly  sutured 

4  Keen's   Surgery,   Vol.  V,   page   138. 


STRUCTURE    AND    HISTOLOGY    OF    BLOOD-VESSELS.  2 1 

wound  in  an  artery  "is  equivalent  ultimately  to  a  com- 
plete and  perfect  regeneration  of  all  the  histologic  ele- 
ments which  enter  into  the  formation  of  the  arterial  wall, 
the  elastic  and  muscular  elements  being  reproduced  as 
perfectly  as  the  baser  elements,  if  the  specimens  are  exam- 
ined long  enough  (at  least  one  hundred  days  in  dogs)  to 
allow  the  regeneration  of  the  elastic  and  muscular  tissue 
to  be  complete."  He  further  says  that  "clinical  experi- 
ence fully  confirms  the  histologic  possibility  of  the  com- 
plete regeneration  of  the  vessels."  An  extensive  inquiry 
made  by  Matas  failed  to  show  that  any  aneurism  has 
formed  at  the  site  of  a  previous  suture. 

Thomaselli5  studied  the  histological  process  of  heal- 
ing in  transverse  wounds  of  the  blood-vessels.  He  says 
the  muscular  layer  is  completely  regenerated,  and  the 
elastic  fibers  of  the  media  are  regenerated  and  are  more 
numerous  along  the  scar  and  near  the  lumen.  They 
do  not  form  a  true  inner  elastic  membrane  but  practically 
replace  it.  The  elastic  fibers  in  the  adventitia  are  not 
regenerated,  the  new  adventitia  consisting  of  connective 
tissue.  Close  to  the  sutures  there  is  entire  restoration 
of  the  three  layers,  though  the  muscle  cells  and  elastic 
fibers  are  hypertrophied. 

De  Gartano  reported  perfect  restoration  of  all  the  ves- 
sel wall,  including  the  elastic  fibers.  Stephen  H.  Watts, 
after  histologic  examination  of  sections  from  sutured 
blood-vessels,  says  that  at  periods  of  from  twenty-eight 
to  eighty-two  days  after  operation  there  is  a  gradual  res- 
toration of  the  artery  at  the  site  of  suture  and  all  the  ele- 
ments of  the  vessel  wall  except  the  inner  elastic  mem- 
brane are  probably  regenerated. 

E.  Archibald  Smith6  states  that,  as  the  immediate  re- 

5  Clinica    Chirurgia,    1902,    No.    6,    and    1903,    XI,    No.    5 ;    Central,    fur    Chirurgie, 
XX,    1906. 

6  Suture   of   Arteries,    Oxford   University    Press. 


28  SURGERY    OF    THE    BLOOD-VESSELS. 

suit  of  suturing  arteries,  necrosis  occurs  in  that  portion 
of  the  wall  of  the  blood-vessel  subject  to  the  direct  pres- 
sure of  the  stitch.  This  includes  all  of  the  elements, 
though  the  elastic  tissue  withstands  more  pressure  than 
the  muscle  or  the  fibrous  tissue,  as  determined  by  the 
fact  that  elastic  tissue  reacts  longer  after  special  stain. 
In  the  center  of  this  small  area  of  necrosis  is  a  micro- 
scopically narrow  cleft  that  opens  into  the  lumen  of  the 
vessel  and  contains  a  small  thrombus.  This  thrombus  in 
successful  vessel  suturing  does  not  protrude  to  a  per- 
ceptible extent  into  the  lumen  of  the  vessel.  A  small 
amount  of  such  thrombus  is  necessary  for  complete 
hemostasis  as  is  more  fully  described  in  the  chapter  on 
technique  (page  46). 

According  to  Smith,  from  the  end  of  the  first  week 
granulation  tissue  is  present  in  the  neighborhood  of  the 
wound  in  the  vessel.  Many  new  capillaries  and  fibro- 
blasts  invade  the  sutured  area  from  without  and  in  this 
manner  the  fibrin  is  absorbed  and  disappears  in  ten  days. 
Long  before  this  time,  however,  endothelium  has  grown 
over  the  fibrin  deposited  around  the  sutures  and  fur- 
nishes a  complete  endothelial  lining  for  the  vessel.  The 
numerous  small  capillaries  gradually  disappear  and  new 
spindle  forms  and  fibrous  elements  are  seen.  Last  of  all 
occurs  the  formation  of  specific  tissues,  of  new  elastic  and 
muscular  elements,  in  the  young  scar.  This  happens 
from  three  to  four  months  after  operation  and  follows 
the  normal  histologic  layers.  Elastic  tissue  appears  as 
extremely  delicate  fibers.  At  this  time  the  suture  ma- 
terial exists  as  a  small  remnant,  being  partly  disinte- 
grated by  the  granulation  tissue  and  gradually  pushed 
away  from  the  lumen  of  the  vessel. 


CHAPTER  II. 

THE  INDICATIONS  FOR  BLOOD-VESSEL 
SUTURING. 

The  marked  attention  paid  to  surgery  of  the  blood- 
vessels in  recent  years  has  excited  unusual  interest  and 
has  been  the  cause  of  many  extravagant  statements,  par- 
ticularly as  regards  suturing  blood-vessels.  The  sensa- 
tional articles  that  have  appeared  in  the  public  press  have 
been  to  a  large  extent  unwarranted,  though  the  modern 
method  of  suturing  blood-vessels  is  one  of  the  great  ad- 
vances in  surgery.  As  is  stated  in  the  work  by  C.  C. 
Guthrie  on  "Blood- Vessel  Surgery,"  " Heterograf ts  suc- 
ceed at  first,  but  inevitably  fail  after  the  first  few  weeks. 
This  is  the  disappointing  but  unanimous  conclusion  of 
experimenters.  Thus  there  is,  at  present,  no  temptation 
for  the  enthusiastic  surgeon  to  try  and  graft  one  lobe  of 
the  thyroid  or  a  kidney  taken  from  a  healthy  donor.  The 
poor  man  will  not  be  tempted  to  exchange  one  of  his 
sound  kidneys  for  so  much  hard  cash."  Lexer1  says 
that  even  in  animals  transplantation  of  limbs  promises 
practically  nothing,  "since,  besides  ischaemic  inflamma- 
tion and  contraction,  it  is  followed  by  hemorrhagic  infil- 
tration and  nerve  disintegration." 

The  idea  that  a  new  limb  can  be  transplanted  and  will 
remain  useful,  or  that  a  kidney  or  thyroid  can  be  grafted 
from  one  individual  to  another,  is  erroneous.  These  ex- 
periments even  in  animals  have  not  been  permanently  suc- 
cessful. A  kidney  transplanted  from  one  dog  to  an- 

1  Annals  of   Surgery,    August,    1914. 

29 


30  SURGERY    OF    THE    BLOOD-VESSELS. 

other  may  functionate  for  awhile,  but  sooner  or  later  the 
fine  differences  of  serum  and  tissue  destroy  the  organ 
and  prevent  ultimate  success.  However,  while  compli- 
cated glands  cannot  be  transplanted,  simpler  tissue  can 
often  be  permanently  grafted  from  one  animal  to  an- 
other, or  particularly  from  one  portion  of  an  animal  or 
person  to  another  portion  of  the  body.  The  simple  func- 
tion of  a  transplanted  blood-vessel  can  be  maintained  and 
it  is  probable  that  at  least  the  endothelial  and  connective 
tissue  of  the  transplanted  vessel  is  permanent. 

The  modern  suturing  of  blood-vessels  has  five  distinct 
fields  aside  from  the  older  method  of  ligation:  (1)  The 
treatment  of  wounded  blood-vessels.  Here  direct  suture 
can  be  used,  or  if  much  of  the  vessel  has  been  injured  a 
segment  of  some  vein  from  the  patient's  own  body,  as 
the  saphenous,  can  be  sutured  into  the  defect.  (2)  Ex- 
cision of  malignant  tumors  that  have  heretofore  been 
considered  inoperable  because  of  involvement  of  a  large 
blood-vessel.  A  section  of  the  vessel  can  be  removed 
and  the  vessel  repaired  as  after  trauma.  (3)  Aneurisms 
can  be  treated  in  a  similar  way,  though  on  account  of  the 
diseased  condition  of  the  vessel  wall  in  spontaneous 
aneurisms,  suturing  is  not  likely  to  be  quite  so  satisfac- 
tory as  in  traumatic  aneurisms.  However,  several  suc- 
cessful cases  have  been  reported  where  spontaneous 
aneurisms  have  been  excised  and  a  segment  of  vein  sub- 
stituted. (4)  Transfusion  of  blood.  This  can  be  done 
by  a  variety  of  methods,  but  the  union  by  sutures  if  prop- 
erly done  is  probably  the  most  satisfactory  method  of 
transfusing  blood.  (5)  Eeversal  of  the  circulation  may 
have  a  limited  field. 


CHAPTER  III. 
HISTORY  OF  BLOOD-VESSEL  SURGERY. 

Surgery  of  the  blood-vessels  began  with  the  first  ef- 
forts to  staunch  the  flow  of  blood  and  is  probably  the 
most  venerable  of  any  branch  of  surgery.  Warren  ' 
gives  the  first  recorded  use  of  the  ligature  as  occurring 
in  1500  B.  C.,  when  Susrutas  employed  it  in  tying  the  um- 
bilical cord.  But  no  mention  is  made  by  Susrutas  of  its 
use  in  surgery,  nor  do  the  early  Egyptian  writings  say 
anything  of  the  ligature.  The  Alexandrian  school  prob- 
ably employed  the  ligature  but  the  records  of  this  work 
were  in  all  likelihood  destroyed  when  the  library  was 
burned.  Aulus  Celsus  (25  B.  C.  to  45  A.  D.)  who  lived 
about  the  beginning  of  the  Christian  era  recommended 
the  ligature  in  surgery  in  certain  cases.  Celsus  was 
classed  by  Pliny  as  a  man  of  letters  (auctor)  rather  than 
a  doctor  (medicus),  and  was  ignored  by  the  Roman  prac- 
titioner of  his  day.  He  wrote  very  extensively  on  medi- 
cal subjects.  His  seventh  book  is  surgical  and  contains 
probably  the  first  account  of  the  use  of  the  ligature  in 
surgery.  It  is  doubtful,  however,  if  his  recommenda- 
tions were  put  into  very  extensive  practice  by  his  col- 
leagues. Galen  (131-211  A.  D.)  mentions  the  ligature 
frequently.  He  was  not  a  practical  surgeon  and  avoided 
the  use  of  the  knife  unless  as  a  last  resort.  He  used  silk 
and  linen  and  tells  where  he  obtained  his  ligatures,  at 
* '  the  shop  on  the  Via  Sacra  between  the  temple  Roma  and 

i  Healing   of   Arteries,    Wm.   Wood   &    Company. 

31 


32  SURGERY    OF    THE    BLOOD-VESSELS. 

the  Forum."  Antyllus,  in  the  third  century,  not  only 
used  the  ligature  but  devised  an  operation  for  aneurism 
which  still  bears  his  name — ligating  the  artery  close  to 
the  aneurism,  both  proximally  and  distally,  and  incising 
the  sac.  This  method  has  given  remarkably  good  re- 
sults. Paulus  ^Egineta  (625-690  A.I).)  mentions  the 
ligature  often.  Torsion  is  not  referred  to  by  him  though 
it  was  described  by  Oribasus  (326-403  A.  D.)  in  connec- 
tion with  an  operation  on  hernia.  The  actual  cautery 
and  various  styptics  were  generally  used  to  control  bleed- 
ing. Ehazes  (850-922  A.  D.)  and  Abucasis  (1106)  used 
the  ligature,  but  preferred  as  a  rule  styptics  and  the 
actual  cautery.  The  latter  wrote  a  book  on  the  cautery. 

Ambrose  Pare  revived  the  use  of  the  ligature  and  in 
1552,  wrote  earnestly  advising  its  employment.  He  used 
a  mass  ligature,  without  attempting  to  isolate  the  vessel. 
The  ligature  did  not  come  into  general  favor,  however, 
for  more  than  a  hundred  years  after  Fare's  time.  Even 
his  pupil  and  friend,  Guillemeau,  often  employed  the  cau- 
tery. When  we  consider  that  the  ligature  of  Pare  was 
employed  en  masse,  including  the  adjacent  nerves,  and 
that  sloughing  and  suppuration  nearly  always  followed, 
and  often  secondary  hemorrhage,  we  can  readily  under- 
stand why  surgeons  were  not  enthusiastic  about  this 
method  of  controlling  hemorrhage.  It  is  interesting  to 
note  that  the  reputations  of  the  three  surgeons,  whom 
Garrison  2  selects  as  the  greatest  surgeons  of  all  times, — 
Ambroise  Pare,  John  Hunter,  and  Lister, — are  founded 
chiefly  or  in  large  part  upon  the  use  of  the  ligature. 

John  Hunter  (1728-1793)  devised  the  principle  of  treat- 
ing aneurisms  due  to  arterial  disease  by  means  of  a  single 
ligature  applied  on  the  proximal  portion  of  the  artery  at 
some  distance  from  the  sac,  at  a  point  where  the  artery 

2  History   of   Medicine,   W.    B.    Saunders   Co. 


HISTORY    OF    BLOOD-VESSEL    SURGERY. 

was  supposed  to  be  healthy.  Guillemeau  (1594)  and 
Anel  (1710)  had  used  the  single  ligature  close  to  the  aneu- 
rism, and  Autyllus  two  ligatures,  proximally  and  distal ly, 
and  an  incision  into  the  sac.  AValdrop  (1782-1869)  cm- 
ployed  the  ligature  distally  in  treating  aneurism,  though 
Pierre  Brasdor  (1721-1797)  first  suggested  the  use  of  a 
distal  ligature.  In  this  way  all  combinations  for  the 
application  of  the  ligature  were  exhausted  and  a  new 
treatment  for  aneurisms  must  be  based  on  something 
other  than  the  ligature. 

The  history  of  the  suturing  of  blood-vessels  is  of  much 
more  recent  origin  than  the  history  of  ligation.  Hallo- 
well,  an  English  surgeon,  first  sutured  the  brachial  artery 
in  man  in  1759.  This  was  suggested  to  him  by  Lambert. 
In  1772,  Assmann,  of  Groningen,  after  unsuccessful  ex- 
periments on  dogs,  announced  that  suturing  arteries  was 
not  feasible.  This  opinion  apparently  held  good  for 
more  than  a  hundred  years  as  Gluck,  in  1881,  was  one  of 
the  first  to  renew  efforts  to  repair  wounded  blood-vessels. 
Gluck  found  the  sutures  would  often  pull  out  and  em- 
ployed small  ivory  clamps  to  close  the  wound,  leaving 
them  in  place.  He  had  some  successful  results. 

In  1879,  Eck,  a  Russian  surgeon,  probably  first  ac- 
complished the  union  of  two  blood-vessels  when  he  estab- 
lished a  communication  between  the  portal  vein  and  the 
vena  cava,  which  is  now  known  as  Eck's  fistula. 

Von  Horoch,  in  1888,  experimented  with  suturing  arter- 
ies, using  silk  and  catgut,  but  thrombosis  resulted  after 
all  his  experiments.  In  1889,  Jassinowsky,  after  twenty- 
six  experiments  on  the  lower  animals,  attained  consider- 
able success  in  repairing  variously  shaped  wounds  of  the 
arteries.  In  many  of  his  experiments  the  bleeding  from 
the  wounded  vessel  was  controlled  and  its  lumen  was  pre- 
served. Twenty-two  of  the  twenty-six  experiments  were 


34  SURGERY    OF    THE    BLOOD-VESSELS. 

successful.  He  used  fine  curved  needles  and  fine  silk 
and  did  not  penetrate  the  intima.  The  sutures  were  in- 
terrupted, and  about  one  millimeter  apart,  He  recom- 
mended thorough  asepsis,  smooth  edges  of  the  wounded 
vessel,  and  penetration  of  only  the  two  outer  coats.  His 
research  is  one  of  the  most  important  in  establishing  ar- 
terial suturing. 

Robert  Abbe,  of  New  York,  published  in  1894  the  re- 
sults of  his  experiments  in  which  he  divided  an  artery  and 
united  it  again  by  suturing  the  ends  over  a  thin  glass 
tube.  In  1896,  Briau  and  Jaboulay  attempted  experi- 
mentally to  unite  the  divided  ends  of  an  artery  by  an  in- 
terrupted mattress  stitch  that  penetrated  all  coats  and 
everted  the  intima.  The  experiments  were  not  very  suc- 
cessful. They  did  ten  operations  on  the  carotid  arteries 
of  dogs,  and  all  of  the  vessels  later  became  thrombosed. 
Afterwards  they  tried  the  same  method  on  the  carotid  of  a 
donkey  with  perfect  results. 

John  B.  Murphy,  in  1897,  published  a  method  by  which 
the  proximal  end  of  an  artery  was  invaginated  into  the 
distal  end  by  means  of  two  mattress  sutures,  which  were 
inserted  so  as  to  draw  the  proximal  end  into  the  distal 
end.  This  materially  diminishes  the  caliber  and  can 
only  be  done  in  large  vessels.  Of  thirteen  experiments, 
three  were  successful.  Murphy  reports  one  case  in 
which  this  operation  was  done  for  a  wound  of  the  femoral 
artery.  After  the  operation  was  completed  there  was  no 
leakage  and  pulsation  appeared  in  the  artery  below  the 
point  of  union.  The  patient  made  a  good  recovery. 
This  is  the  first  successful  end-to-end  union  of  an  artery 
in  man. 

In  1897  and  1898,  Silverberg  experimented  with  arterial 
suture  in  dogs.  He  used  the  finest  silk  and,  with  three 
exceptions,  employed  the  continuous  suture  instead  of  the 


HISTORY    OF    BLOOD-VESSEL    SURGERY. 


35 


interrupted.     He  did  not  attach  much  importance  to  the 
inclusion  of  the  intima. 

In  1898,  Gluck,  who  had  also  done  excellent  work  in  the 
lateral  suturing1  of  arteries,  devised  a  method  of  end-to- 
end  union  by  which  he  removed  completely  a  small  sec- 
tion of  an  artery,  slipped  it  over  one  end  of  the  artery  as 


Fig.  9. — Payr's  magnesium  tubes  and  discs  for  uniting  arteries.  (A)  The  mag- 
nesium ring  with  a  groove,  which  has  been  passed  over  the  end  of  an  artery. 
(B)  Transverse  section  of  the  completed  operation.  (C)  A  later  modifica- 
tion of  the  tube  by  Payr. 

a  ring,  and  after  the  ends  were  united  it  was  drawn  over 
the  suture  line  to  reenforce  the  sutures  and  held  in  this 
position  by  a  few  stitches.  Other  substances,  he  says, 
such  as  rings  of  rubber  or  decalcified  bone  may  be  em- 
ployed. 

In  1899,  Dorfler  published  the  results  of  his  experi- 
ments and,  according  to  Guthrie,  established  the  main 
features  of  the  methods  that  are  now  so  generally  used. 
Dorfler  claimed  that  the  essentials  of  successful  blood- 
vessel suturing  were  fine,  round  needles ;  fine  silk ;  and  a 
continuous  suture  embracing  all  coats  of  the  vessels.  He 


36  SURGERY    OF    THE    BLOOD-VESSELS. 

did  not  avoid  the  intima,  but  recommended  that  all  coats 
be  included  in  the  continuous  suture. 

Payr,  in  1900,  gave  a  great  stimulus  to  surgery  of  the 
blood-vessels  by  devising  a  ring  of  magnesium.  This  was 
a  circular  band  shaped  like  a  diminutive  napkin  ring 
with  a  groove  in  its  outer  surface  (Fig.  9).  This  ring 
was  slipped  over  the  central  end  of  an  artery  and  the 
artery  cuffed  back  and  tied  in  the  groove.  The  distal  end 
of  the  artery  was  then  stretched,  invaginated  over  the 
cuff,  and  held  in  position  by  another  ligature.  In  this 
manner  intima  was  approximated  to  intima  and  the  mag- 
nesium was  in  the  course  of  time  absorbed.  The  method 
was  tried  rather  extensively  both  experimentally  and 
clinically.  According  to  Crile,  his  transfusion  cannula  is 
a  modification  of  the  ring  of  Payr.  Payr's  idea  was  that 
sutures  would  probably  not  hold  and  that  this  method 
would  withstand  arterial  pressure.  In  1904,  Payr  pub- 
lished an  article  giving  his  own  experiments  and  those  of 
others  and  claimed  that  unsuccessful  results  were  due  to 
the  fact  that  his  directions  were  not  followed.  He  also 
devised  two  discs  of  magnesium  with  small  pins  on  the 
periphery  of  one  disc  which  fit  into  holes  in  the  opposite 
disc.  The  end  of  the  vessel  was  placed  through  the  disc, 
opened  widely  to  evert  the  intima,  and  fixed  by  the  pins 
which  both  transfixed  the  walls  of  the  vessels  and  clamped 
the  opposite  disc. 

Bougie,  in  1901,  introduced  a  new  method  of  invagina- 
tion,  a  modification  of  Murphy's,  in  which  the  ends  were 
invaginated  only  a  short  distance  and  fastened  with  su- 
tures that  did  not  penetrate  the  intima  of  the  proximal 
end. 

In  1902,  many  articles  appeared,  among  which  were 
those  of  Thomaselli,  Salvia  and,  particularly,  Carrel. 
Salvia  experimented  upon  dogs,  donkeys,  and  sheep  and 


HISTORY    OF    BLOOD-VESSEL    SURGERY.  37 

paid  special  attention  to  the  healing  of  the  arterial  wound. 
He  used  end-to-end  sutures  of  fine  silk.  In  none  of  his 
cases  did  the  lumen  remain  open.  Thomaselli  laid  much 
stress  upon  approximating  intima  to  intima.  He  used  in- 
terrupted sutures  passed  through  all  coats  with  fine, 
curved  needles  and  silk.  In  a  later  article  he  says  that 
the  method  of  Salomoni  is  the  best. 

Carrel  published  his  well  known  method  in  1902.  It 
differs  in  no  essential  particular  from  the  work  of  others, 
but  is  a  combination  of  the  best  features  of  other 
work.  The  results  obtained  were  much  better  than  those 
secured  by  any  one  else.  He  used  very  fine,  No.  16,  round, 
straight  needles,  threaded  with  fine  silk  impregnated  with 
vaseline.  The  adventitia  is  thoroughly  removed  and  the 
ends  of  the  artery  washed  out  with  salt  solution,  or 
Ringer's  solution.  The  ends  of  the  vessels  are  then 
united  by  three  traction  sutures  inserted  around  the  ar- 
tery at  equidistant  points  (Fig.  10).  Traction  on  the 
sutures  converts  the  circumference  of  the  artery  into  a 
triangle,  approximates  the  intima,  and  renders  the  su- 
turing easy.  The  operator  holds  one  traction  suture,  the 
assistant  holds  another,  and  the  third  is  caught  in  a  small 
hemostatic  forceps,  so  as  to  pull  the  artery  away  from  the 
region  that  is  being  sutured.  After  suturing  one-third 
with  a  continuous  overhand  stitch  the  operator  takes 
the  suture  held  by  the  assistant,  the  assistant  takes  the 
one  to  which  the  hemostat  was  fastened,  and  the  hemo- 
stat  is  placed  upon  the  traction  suture  that  the  operator 
originally  held.  After  the  second  third  is  finished  the 
traction  sutures  are  again  changed,  the  operator  tak- 
ing the  one  held  by  the  assistant,  who  makes  tension  on 
the  suture  that  was  clamped  by  the  hemostat  and  the 
hemostat  is  placed  on  the  suture  just  released  by  the  oper- 
ator. The  last  third  is  now  completed  and  the  current  is 


38 


SURGERY    OF    THE    BLOOD-VESSELS. 


turned  on  gently.  Slight  pressure  usually  stops  the  ooz- 
ing from  the  needle  holes,  and  then  the  full  force  of  the 
stream  is  released. 

Very  brilliant  results  have  been  secured  by  this  tech- 
nique in  the  hands  of  Carrel,  Guthrie,  Stephen  H.  Watts, 


Fig.  10. — Carrel's  method  of  end-to-end  suture  of  arteries.  (A)  Three  guy  sutures 
inserted  and  ready  to  be  tied.  (B)  The  guy  sutures  tied  and  one  clamped 
with  a  hemostat.  (C)  The  suturing  of  one-third  has  almost  been  completed. 
(D)  The  operation  completed. 

and  others.  Watts  reported,  in  1907,  a  remarkable  series 
of  experiments  on  dogs  in  which  this  technique  was  used. 
Of  thirteen  circular  sutures  of  the  carotid,  all  were  per- 
fectly successful  and  there  was  not  the  slightest  evidence 


HISTORY    OF    BLOOD-VESSEL    SURGERY.  39 

of  thrombus  formation.  In  two  instances  when  the 
femoral  artery  was  sutured,  thrombosis  occurred.  Thir- 
teen times  the  jugular  vein  was  divided  and  sutured  with 
ten  successes.  Microscopical  examination  of  the  arterial 
specimens  at  periods  varying  from  twenty-eight  to  eighty- 
two  days  after  operation  showed  a  gradual  restoration  of 
the  artery  at  the  site  of  suture,  all  elements  of  the  vessel 
wall  being  regenerated  except  the  inner  elastic  membrane. 
Watts  also  reversed  the  circulation  in  the  neck  by  sutur- 
ing the  central  end  of  the  carotid  artery  to  the  distal  end 
of  the  external  jugular  vein.  This  was  done  four  times, 
all  being  successful.  Examination  of  the  veins  from 
one  to  three  months  after  operation  showed  a  dilatation 
of  the  vein  with  thickening  of  the  walls.  Microscopic  ex- 
amination showed  changes  very  much  like  those  found  in 
arteriosclerotic  arteries.  He  excised  and  reimplanted  a 
section  of  the  femoral  artery  but  thrombosis  occurred. 
Twice  he  transplanted  a  section  of  vein  between  an 
artery,  using  a  section  of  the  external  jugular  between  the 
ends  of  the  carotid  in  one  instance  and  between  the  di- 
vided femoral  in  another.  The  carotid  experiment  was 
successful,  but  the  transplantation  into  the  femoral  artery 
resulted  in  thrombosis. 

In  1901,  Clermont  reported  experiments  on  suture  of 
the  veins.  He  used  a  continuous  mattress  stitch  of  fine 
silk  and  everted  the  edges  of  the  vessel.  He  devised  a 
method  by  which  the  intima  was  united  to  intima  by  a 
continuous  mattress  suture  of  fine  silk  with  a  second  row 
of  overhand  running  sutures  uniting  the  edges. 

In  1903,  Jensen  published  an  article  on  the  circular 
suturing  of  blood-vessels,  which  was  very  complete.  He 
preferred  silk  and  sutured  all  coats  of  the  vessel  with  a 
continuous  stitch.  Hoefner,  in  1903,  gave  a  history  of 
lateral  and  circular  suturing  of  blood-vessels  in  ani- 


40  SUEGEEY    OF    THE    BLOOD-VESSELS. 

mals  and  man,  and  also  the  results  of  his  own  experi- 
ments, using  the  magnesium  ring  of  Payr. 

In  the  same  year  Amberg  reported  experimental  work 
in  which  the  ends  of  the  vessel  were  split  longitudinally 
so  as  to  afford  a  greater  surface  of  intima.  This  prac- 
tically converted  the  vessel  end  into  two  flaps  which  were 
united  by  sutures.  The  experiments,  however,  were  only 
fairly  successful,  as  in  only  half  of  the  operations  was  the 
lumen  preserved. 

Da  Gaetano  reported,  in  1906,  a  method  in  which  he 
used  a  small  spindle-shaped  glass  bobbin  for  suturing  lat- 
eral wounds  of  vessels  or  for  end-to-end  union.  After 
the  sutures  are  placed  and  before  they  are  drawn  tight, 
the  bobbin  is  removed.  He  used  fine  silk  and  a  round 
needle  and  did  not  perforate  the  intima.  He  reported 
satisfactory  results  functionally  and  histologically,  find- 
ing new  muscle  and  elastic  tissue  in  the  vessel  scar  within 
four  months. 

In  1906,  Dorrance  published  an  article  in  which  he 
recommended  that  vessels  be  sutured  by  a  continuous  mat 
tress  stitch  in  which  every  third  stitch  was  a  back  stitch 
so  as  to  lock  the  line  of  sutures.  After  completing  the 
suturing  in  this  manner  another  row  of  overhand  stitches 
was  placed  to  reenforce  the  sutures  after  the  manner  of 
Clermont  (Fig.  11).  In  a  personal  communication,  Dr. 
Dorrance  says  he  has  dispensed  with  the  second  row  of 
sutures  as  being  unnecessary. 

Stich,  Makkas  and  Dowman,  in  1907,  reported  results  of 
experiments  with  a  technique  very  similar  to  that  of 
Carrel,  using  fine  needles  and  silk  which  they  immerse  in 
liquid  paraffin  before  using.  They  not  only  did  circular 
suture  of  the  arteries,  but  successfully  transplanted  a  seg- 
ment of  a  cat's  aorta  between  the  ends  of  a  divided  caro- 
tid of  a  dog. 


HISTORY    OF    BLOOD-VESSEL    SUEGERY. 

E.  Archibald  Smith,3  in  a  small  monograph,  reviews  the 
literature  of  blood-vessel  suturing  and  gives  in  detail  flu- 
results  of  experiments  with  a  method  of  his  own.  This 
consists  of  a  "quill"  suture  in  which  chromic  catgut  is 
used  for  "quills."  Interrupted  mattress  sutures  are 
placed,  everting  the  intima,  and  a  strand  of  chromic  cat- 
gut is  carried  under  the  loop  of  each  suture,  as  in  the  old 


Fig.  11. — Dorrance's  method  of  suturing  arteries.  (A)  The  artery  is  partly  sutured 
with  a  mattress  stitch  which  drops  back  about  every  third  stitch.  (B)  The 
operation  completed  with  an  overhand,  reenforcing  stitch.  Dorrance  has  now 
abandoned  the  overhand  stitch  as  being  unnecessary. 

quill  suture.  Another  strand  of  chromic  catgut  is  placed 
between  the  ends  of  each  suture  and  the  suture  is  tied 
snugly  on  the  catgut.  Less  than  a  third  of  his  experi- 
ments were  successful. 

Lespinasse,  Fisher  and  Eisenstaedt,  of  Chicago,4  pub- 
lished excellent  results  of  experimental  work  on  end-to- 
end  anastomosis  of  blood-vessels  and  on  closing  wounds 

3  Suture  of  Arteries,   Oxford  University   Press,   1909. 

4  Journal  A.  M.  A.,  November  19,   1910. 


42  SUEGEEY    OP    THE    BLOOD-VESSELS. 

in  arteries  or  veins.  For  lateral  wounds  they  recom- 
mend perforated  plates  of  magnesium.  A  perforated 
plate  is  placed  on  each  side  of  the  wound  and  holds  the 
intima  of  the  wound  in  contact  by  means  of  mattress 
sutures  that  are  passed  through  the  perforation  and  both 
lips  of  the  wound.  For  end-to-end  union,  the  magnesium 
is  in  the  shape  of  discs  or  rings,  resembling  the  second 
device  of  Payr,  which  have  a  number  of  small  holes  along 
the  periphery.  The  end  of  the  vessel  is  carried  through 
the  rings  and  fastened  by  four  sutures  to  these  holes. 
This  flares  open  the  end  of  the  vessel  and  exposes  the  in- 
tima. Both  ends  are  placed  through  the  magnesium  rings 
in  this  manner  and  then  the  rings  are  brought  together 
and  fastened  firmly  by  mattress  sutures  passed  through 
the  opposing  perforations. 

The  Journal  of  the  American  Medical  Association,  May 
10, 1913,  page  1474,  says :  "Lexer  of  Jena,  showed  a  case 
of  ideal  operation  for  aneurism  and  transplantation  of  the 
vessels.  The  patient  was  operated  on  according  to  the 
rules  established  by  Lexer  in  1907.  To  maintain  the 
circulation  in  its  normal  channel,  the  spindle-shaped  aneu- 
rism beginning  above  Poupart's  ligament  and  extending 
below  the  arteria  profunda  was  removed  and  the  defect 
of  the  vessel  repaired  by  the  introduction  of  a  piece  of 
saphenous  vein,  18  cm.  long.  The  wall  of  the  artery 
markedly  changed  by  arteriosclerosis  allowed  the  thread 
of  the  running  suture  of  Carrel  to  cut  through.  On  the 
other  hand,  the  continuous  protruding  mattress  suture 
gave  very  good  service ;  the  thread  not  only  held  well  but 
also  prevented  hemorrhage.  The  large  differences  in 
lumen  of  the  piece  of  vein  and  that  of  the  still  enlarged 
artery  caused  little  difficulty  in  suture.  The  brilliant  re- 
sult also  shows  that  the  piece  of  vein  must  have  under- 


HISTORY    OF    BLOOD-VESSEL    SURGERY.  4o 

gone  an  increase  in  size,  as  in  experimental  work.  The 
patient  was  a  man  aged  sixty-two  and  the  case  testifies 
beyond  cavil  that  a  transplanted  vessel  may  remain  thor- 
oughly permeable.  The  arteries  in  the  foot  now  pulsate 
as  powerfully  as  those  on  the  other  side,  but  they  imme- 
diately become  pulseless  when  the  femoral  artery  in  the 
region  of  the  transplanted  vessel  is  compressed.  The  pa- 


1!. 


Fig.  12. —  (A)  Mattress  suture  applied  in  a  lateral  wound  as  recommended  by 
Bickham.  (B)  Mattress  suture  with  it  reenforcing  stitch  in  a  transverse 
wound.  (Bickham.) 

tient,  who  was  operated  on  nine  months  ago,  is  completely 
free  from  symptoms." 

Soresi,  of  New  York,  described  before  the  Seventeenth 
International  Medical  Congress  an  apparatus  for  sutur- 
ing blood-vessels  which  consists  of  a  small  clamp  that 
kept  the  vessels  approximated.  Minute  hooks  held  a 
turned  back  cuff  and  exposed  the  intima.  The  intima 


44  SURGERY    OF    THE    BLOOD-VESSELS. 

was  then  approximated  to  intima  by  means  of  very  small 
gold  wire  clamps  somewhat  after  the  fashion  of  Michel 
skin  clamps.5 

Christian  and  Saunderson G  described  a  device  for  unit- 
ing blood-vessels  by  means  of  two  metal  rings  and  a 
holder.  From  the  surface  of  each  ring  several  very 
small  bearded  points  project.  The  vessel  is  cuffed  back 
over  each  ring  and  held  by  the  sharp  points.  The  two 
rings  are  fastened  together  with  small  pliable  wires  one- 
fourth  of  an  inch  long  which  project  from  the  side  of 
the  ring  and  which  are  fastened  together  by  being  twisted 
with  pliers. 

John  W.  Price,  Jr.,7  of  Louisville,  has  devised  a  method 
of  suturing  blood-vessels  by  means  of  a  new  instrument. 
"This  instrument  is  a  cannula-forceps.  The  cannula 
portion  is  spooled  slightly  at  one  end.  The  instrument 
is  made  in  several  sizes,  so  that  a  cannula  will  have  a 
bore  of  11/2  mm.,  2  mm.,  2y2  mm.,  3  mm.,  or  larger  if  de- 
sired. The  cannula-forceps  may  be  used  in  making  a 
temporary  anastomosis  between  two  blood-vessels,  as  for 
a  transfusion;  for  making  a  permanent  end-to-end  or 
end-to-side  anastomosis  between  two  vessels. 

"1.  The  cannula  is  opened  and  then  closed  to  include 
one  vessel  about  3  to  4  mms.  from  its  cut  end  (the  spooled 
end  of  the  cannula  is  toward  the  cut  end  of  the  vessel) ; 
the  end  of  the  vessel  is  then  caught  by  three  iris  hooks 
from  within  and  cuffed  over  the  spooled  portion  of  the 
cannula  and  held. 

"2.  The  end  of  the  second  vessel  is  now  caught  from 
within  by  three  iris  hooks  and  pulled  over  the  everted 
vessel  on  the  end  of  the  cannula,  thus  the  endothelial  sur- 


5  Journal  A.   M.   A.,   September   16,    1913,   page   800. 

6  New   Orleans   Medical   and   Surgical  Journal,    November, 

7  The   Lancet-Clinic,   January   25,    1913. 


1913. 


HISTORY    OF    BLOOD-VESSEL    SUEGERY.  45 

face  of  one  vessel  is  brought  next  to  the  endothelial  sin- 
face  of  the  other. 

"3.  Two  iris  hooks  are  now  passed  through  both  vessels 
and  held,  the  first  set  of  hooks  being  removed. 

"4.  A  continuous  mattress  suture  is  inserted  through 
all  the  coats  of  both  vessels  at  their  approximated  ends. 

"5.  Hooks  are  removed. 

"6.  The  cannula  is  then  slipped  out  of  the  cuff  (away 
from  the  line  of  sutures),  opened  and  removed. 

"7.  The  Crile  clamp  on  the  vessel  distal  to  the  anasto- 
mosis is  removed  first,  then  the  proximal  clamp  is  re- 
moved, which  allows  the  blood  to  flow.  Additional 
sutures  are  added  to  control  any  oozing." 

Muir 8  describes  a  method  of  uniting  blood-vessels  by 
means  of  a  bone  cylinder  with  a  ridge  for  the  retention 
of  the  ligature.  The  cylinders  are  made  in  different 
sizes.  The  artery  is  cuffed  back  from  the  cylinder  and 
ligated;  the  operation  is  similar  to  the  technique  used 
in  Payr's  magnesium  rings,  or  in  the  cannula  of  Crile. 
The  bone  is  said  to  absorb,  leaving  no  foreign  body. 

8  Journal-Lancet,    April,    191-1. 


CHAPTER  IV. 

THE  TECHNIQUE  OF  SUTURING   BLOOD- 
VESSELS. 

The  chief  difficulty  to  overcome  in  suturing  blood-ves- 
sels is  occlusion  by  clotting,  and  improvements  in  tech- 
nique are  intended  to  prevent  an  excessive  amount  of 
clotting.  The  physiology  of  thrombus  formation  is  still 
rather  vague,  as  it  is  impossible  to  isolate  chemically 
some  of  the  substances  that  are  involved  in  this  process, 
and  their  presence  has  to  be  taken  for  granted  in  order 
to  support  a  reasonable  hypothesis.  There  are  certain 
general  reactions,  however,  that  all  physiologists  acknowl- 
edge. The  direct  formation  of  a  thrombus  is  due  to  the 
action  of  fibrin  ferment  on  fibrinogen.  Fibrinogen 
exists  normally  in  blood  plasma.  Fibrin  ferment  is 
built  up  from  various  substances  and  is  probably  formed 
from  the  action  of  a  thromboplastic  substance,  called 
by  some  thrombokinase,  upon  thrombogen  in  the  pres- 
ence of  a  solution  of  calcium  salts.  Thrombokinase  is 
not  a  true  kinase  in  the  sense  of  acting  solely  as  a  fer- 
ment, for  it  is  used  up  in  the  process  of  clotting.  Throm- 
bokinase is  the  key  to  the  situation,  and  whether  it  acts 
directly,  or  indirectly,  as  Howell  claims,  by  combining 
with  antithrombin  in  the  blood  and  thus  liberating  pro- 
thrombin  (thrombogen),  it  nevertheless  is  essential  to 
clotting  and  to  a  large  extent  regulates  the  amount  of 
thrombus  formed.  Thrombokinase  is  supposed  to  be 
present  in  all  tissues  of  the  body  and  also  comes  from 

46 


TECHNIQUE    OF    SUTURING   BLOOD-VESSELS.  47 

disorganized  blood  corpuscles,  particularly  the  platelets. 
It  seems  abundant  in  the  adventitia  of  blood-vessels. 

The  practical  bearing  of  these  facts  upon  blood-vessel 
surgery  is  evident,  for  thrombokinase  can  only  be  liber- 
ated from  injured  tissue.  As  the  amount  of  clotting  is 
directly  proportionate  to  the  amount  of  thrombokinase,  it 
is  readily  seen  that  any  undue  injury  to  blood-vessels  by 
rough  handling,  or  by  drying  of  the  endothelial  cells  of 
the  intima,  or  by  the  presence  of  too  much  foreign  sub- 
stance in  the  lumen,  or  by  chemical  or  bacterial  injuries, 
will  result  in  the  liberation  of  so  much  thrombokinase 
that  excessive  thrombus  is  formed  and  the  vessel  is  oc- 
cluded. Even  the  most  successful  suturing  of  blood- 
vessels is  accompanied  by  some  clotting,  but  a  limited 
amount  is  essential  as  it  serves  to  fill  the  punctures  from 
the  needle  holes  and  to  bridge  over  the  line  of  contact. 
In  successful  vessel  suturing,  however,  the  injury  is  so 
slight  that  very  little  thrombokinase  is  released  and  con- 
sequently only  a  small  amount  of  thrombus  is  formed, 
just  enough  to  plug  the  punctures  made  by  the  needle  and 
not  enough  to  obstruct  the  lumen. 

We  recognize,  then,  as  the  principles  for  successful 
blood-vessel  suturing  that  a  continuous  surface  of  vascu- 
lar endothelium  must  line  the  lumen  and  that  as  little  in- 
jury as  possible  must  be  done  this  endothelium.  The  im- 
portance of  presenting  to  the  lumen  of  the  vessel  a  con- 
tinuous surface  of  vascular  endothelium,  is  appreciated 
when  we  recall  what  has  been  learned  in  a  somewhat 
coarser  fashion  by  intestinal  suturing.  Here  it  is  a  well 
recognized  principle,  as  it  is  in  blood-vessel  suturing,  that 
the  endothelial  surfaces  must  be  approximated  accu- 
rately. In  the  case  of  the  bowel,  the  endothelium  is  on  the 
outside  and  it  is  necessary  to  turn  in  a  small  flange  or 
shelf  to  secure  accurate  apposition  of  the  peritoneal  endo- 


48  SURGERY    OP    THE    BLOOD-VESSELS. 

thelium.  In  blood-vessels  the  endothelium  is  on  the  in- 
side and  it  is  essential  to  turn  out  a  flange  in  order  to  ap- 
proximate the  endothelial  lining-  of  the  blood-vessel.  The 
usual  method  of  suturing  blood-vessels  consists  in  first 
placing  three  guy  sutures  and  then  whipping  the  edges  of 
the  vessel  together  by  an  overhand  stitch.  This  neces- 
sarily cannot  approximate  the  endothelial  surface  on  the 
inside  as  accurately  as  would  a  mattress  stitch  that  turns 
out  a  flange  and  compels  the  apposition  of  the  intima. 
No  one  would  think  of  suturing  a  bowel  in  a  similar  man- 
ner and  claim  that  the  peritoneum  could  be  accurately 
brought  together  by  merely  whipping  over  the  margins 
of  the  bowel  wound  as  in  suturing  skin.  If  this  cannot  be 
done  in  intestinal  surgery,  the  same  thing  holds  equally 
in  blood-vessel  surgery. 

The  presence  of  foreign  substances  in  the  lumen  of  a 
blood-vessel  promotes  clotting.  Some  substances  favor 
clotting  more  than  others.  A  coating  of  vaseline  or  par- 
affin retards  clotting.  Other  things  being  equal,  however, 
the  larger  the  amount  of  foreign  substance  or  raw  sur- 
face in  the  blood  vessel,  the  greater  the  likelihood  of  ex- 
tensive clotting.  A  mattress  suture  which  turns  out  a 
flange  not  only  approximates  the  intima  more  accurately 
but  leaves  almost  no  thread  exposed  in  the  lumen; 
whereas  the  continuous  overhand  stitch  leaves  a  consider- 
able amount  of  thread  in  the  lumen.  This  is  readily  seen 
from  the  accompanying  cut  (Fig.  13a)  which  is  repro- 
duced from  Guthrie's  work  on  blood-vessel  surgery  and 
shows  the  inside  of  the  vessel  soon  after  being  sutured 
by  the  usual  method.  The  mattress  suture  which  is 
parallel  to  the  wound  also  secures  a  better  hold  upon  the 
tissues  than  the  overhand  stitch  which  is  at  right  angles 
to  the  wound  and  the  mattress  stitch  is,  consequently,  less 
liable  to  cut  (Fig.  13c).  This  is  due  to  the  fact  that  in 


TECHNIQUE    OF    SUTURING   BLOOD-VESSELS. 


4!) 


the  mattress  suture  the  tension  is  more  equally  distrib- 
uted along  the  whole  loop  of  the  stitch,  whereas  in  the 
overhand  stitch  the  tension  is  concentrated  at  one  point, 
that  is,  at  the  end  of  the  suture  farthest  from  the  wound. 
This  fact  has  been  brought  out  by  Lexer  in  a  case  that 
has  already  been  referred  to  (page  42).  Lexer  excised 


A. 


B. 


0. 


Fig.  13. —  (A)  This  drawing,  reproduced  from  Guthrie,  shows  the  appearance  of  the 
lumen  of  a  blood-vessel  immediately  after  it  is  sutured  by  the  method  of 
Carrel.  Note  the  large  amount  of  thread  exposed  in  the  lumen. 

(B)  This   drawing,    also   from   Guthrie,    shows   the   appearance   of   the   lumen 
of    a   blood-vessel    several    weeks    after    successful    suturing.      The    stitches    have 
been   covered  by   endothelium  which   is   still   partly   transparent.      The   older  the 
specimen,   the  thicker   and   more   opaque  becomes  the  covering  over   the  sutures 
until,    after    several    months,    the    stitches    are    completely    hidden    from    view. 
This    is    true    of    any    method    of    suturing    whether    the    mattress    or    overhand 
stitch    is    used.      It    is    the    first    day    or    two    after    the    suturing     (before    the 
stitches    are    covered)    that    the    amount    of   thread    in    the    lumen    is    important. 
Sutures  seem  to  work  away  from  endothelial  surfaces  toward  the  lumen  in  the 
intestine    and   toward   the   surface   in   blood-vessels. 

(C)  This    drawing   shows   the    aversion   of   the    intima    caused   by    the    double 
mattress    stitch    and    the    consequent    absence    of    any    raw    surface    left    in    the 
lumen   of   the   vessel.      Note   the   very    small    amount    of    thread   left   exposed    to 
the  blood  current   as   compared   with    "A."      Note  also  the   strong  grip   that  the 
loop  of  the  mattress   stitch  has  on  the  tissue. 

an  aneurism  and  sutured  a  piece  of  the  saphenous  vein 
into  the  defect.  "The  wall  of  the  artery  markedly 
changed  by  arteriosclerosis  allowed  the  threads  of  the 
running  suture  of  Carrel  to  cut  through.  On  the  other 
hand,  the  continuous  protruding  mattress  suture  gave 
very  good  service ;  the  thread  not  only  held  well  but  also 
prevented  hemorrhage. ' ' 


50  SURGERY    OF    THE    BLOOD-VESSELS. 

Asepsis  in  blood-vessel  suturing  should  be  as  nearly 
perfect  as  possible,  just  as  it  should  be  in  abdominal  sur- 
gery, brain  surgery,  or  bone  surgery.  If  the  tissues 
around  the  blood-vessels  are  infected  no  suturing  can  be 
expected  to  be  satisfactory.  Yet  even  in  the  presence  of 
infection  it  is  not  invariably  a  failure,  as  the  author  has 
one  successfully  sutured  femoral  artery  in  a  dog  in  which 
the  tissues  around  the  vessel  suppurated  for  several 
weeks.  As  a  rule,  however,  infection  will  result  in  fail- 
ure and  the  proper  aseptic  technique  should  be  insisted 
upon.  Particularly  should  dust  be  avoided.  The  oper- 
ator should  wear  a  mask  over  his  mouth  and  the  floor  of 
the  operating  room  should  preferably  be  moist.  In  labo- 
ratory work  the  floor  should  be  flushed  with  water  an 
hour  or  two  before  operating.  The  manner  of  handling 
tissues  is  most  important,  for  gentleness  is  an  absolute 
essential.  No  matter  how  careful  the  aseptic  technique, 
good  results  cannot  be  secured  by  one  who  uses  the  same 
methods  of  handling  tissue  in  blood-vessel  surgery  as 
would  be  adopted  in  bone  surgery.  The  vascular  endo- 
thelium  should  not  be  permitted  to  dry  and  should  not  be 
touched  with  any  instrument. 

As  for  instruments,  the  author  uses  No.  16  straight 
needles  threaded  with  00000  twisted  black  silk.  They 
are  threaded  with  silk  about  fourteen  inches  long  and  a 
single  knot  is  tied  on  the  eye  of  the  needle  to  prevent  it 
becoming  unthreaded.  The  short  end  should  be  cut 
within  half  an  inch  of  the  needle  to  avoid  unnecessary 
loose  ends  dangling  about.  Five  of  these  threaded 
needles  are  run  through  a  piece  of  gauze  of  double  thick- 
ness about  two  inches  wide  and  as  long  as  the  thread. 
This  gauze  is  then  placed  in  a  small  can  or  ointment  jar 
that  is  one-third  full  of  white  vaseline.  More  vaseline  is 
put  over  the  gauze  and  the  jar  is  closed  and  sterilized. 


TECHNIQUE    OF    SUTURING    BLOOD-VESSELS.  51 


Fig.   14. — Arterial    suture    staff. 


52  SURGERY    OF    THE    BLOOD-VESSELS. 

The  needles  are  not  removed  until  they  are  to  be  used, 
when  they  are  taken  from  the  gauze  and  the  gauze,  which 
is  thoroughly  impregnated  with  vaseline,  is  laid  beneath 
the  artery  to  protect  it  from  the  surrounding  tissue.  To 
place  the  cobbler's  stitch  satisfactorily,  it  is  necessary  to 
have  an  instrument  called  "an  arterial  suture  staff" 
which  the  author  has  devised  in  an  effort  to  simplify  the 
technique.  This  instrument  (Fig.  14)  consists  of  a  small 
steel  shaft  which  curves  at  one  extremity  into  a  shorter 
shaft.  The  long  shaft,  or  handle,  is  six  inches  long,  and 
the  short  shaft  is  one  and  three-quarters  inches  long  and 
is  placed  at  an  angle  of  about  sixty  degrees  to  the  long 
shaft.  The  curved  portion  is  flattened  to  form  a  spring. 
There  are  five  buttons ;  one  on  the  main  shaft  as  close  as 
possible  to  the  curved  spring,  one  at  the  extremity  of  the 
short  shaft,  one  just  below  this,  and  two  on  the  main  shaft 
at  points  about  opposite  the  buttons  on  the  short  shaft. 
These  buttons  hug  the  instrument  closely  and  are  so  con- 
structed that  the  guy  sutures  are  securely  held  by  simply 
wrapping  them  twice  around  the  buttons.1  In  order  to 
occlude  the  vessel,  either  a  rubber  covered  Crile  clamp  is 
used,  or  the  ordinary  serrefine,  or  bulldog  clamp,  uncov- 
ered, which  has  a  spring  so  weakened  that  the  clamp  can 
grasp  the  skin  of  the  forearm  without  pain.  The  inside 
of  the  vessel  should  never  be  caught  with  forceps,  though 
sometimes  it  is  necessary  to  grasp  the  outside.  For  this 
purpose  the  ordinary  thumb  forceps  called  "frog  for- 
ceps" by  the  instrument  dealers  and  sold  for  biological 
dissection  are  excellent.  Several  mosquito  hemostatic 
forceps  are  needed  (Fig.  15).  Aside  from  these  special 
instruments,  the  usual  instruments  may  be  employed. 
The  knife  and  scissors  should  be  sharp. 

1  The  arterial  suture  staff  is  made  by  The  Kny-Scheerer  Company,  of  New  York, 
and  by  Sharp  &  Smith,  of  Chicago.  Powers  &  Anderson,  Inc.,  Richmond,  Virginia, 
keep  in  stock  the  staff  and  the  set  of  instruments  and  sutures  used  in  vessel  suturing. 


TECHNIQUE    OF    SUTURING    BLOOD-VESSELS. 


Fig.  15. — Special  instruments  used  in  end-to-end  suturing  of  blood-vessels.  On  the 
left  is  the  arterial  suture  staff  and  next  to  it  a  small  thumb  forceps  called 
"frog  forceps."  On  the  right  is  a  "mosquito"  hemostatic  forceps  and  next  to 
it  two  serreflnes,  or  "bulldog"  forceps. 


54 


SURGERY    OF    THE    BLOOD-VESSELS. 


The  vessel  is  exposed,  keeping  the  tissues  as  dry  as 
possible.  A  serrefine  is  placed  on  the  portion  of  the 
vessel  nearest  the  heart,  and  the  vessel  is  then  gently 
grasped  between  the  thumb  and  finger  and  stripped  of 
blood  to  the  other  angle  of  the  wound,  where  another 


Fig.  16. — The  artery  is  exposed,  blood  stripped  from  it  and  serrefine  clamps  are 
placed.  Gauze  soaked  in  vaseline  is  under  the  artery.  The  dotted  line  shows 
the  proposed  incision. 

serrefine  is  placed.  This  leaves  the  artery  dry  and  flat 
like  a  ribbon.  The  vaselinized  gauze  from  which  the 
needles  have  been  removed  is  now  placed  beneath  the 
vessel  (Fig.  16),  after  stopping  all  bleeding  in  the 
wound,  and  the  artery  is  divided  with  one  stroke  of  sharp 
scissors.  The  fingers  are  wiped  free  of  blood  and  moist- 


TECHNIQUE    OF    SUTURIXG    BLOOD-VESSELS. 


OO 


ure  on  a  dry  towel  and  the  left  finger  and  thumb  grasp 
one  of  the  ends  of  the  artery  rather  firmly  and  pull  the 
adventitia  over  its  cut  end.  The  adventitia  is  cut  off  on 
a  level  with  the  rest  of  the  artery  (Fig.  17).  It  then 
retracts,  leaving  the  middle  and  inner  coats  exposed. 


Fig.  17. — The  artery  is  severed  by  sharp  scissors.  The  adventitia  curls  over  the 
ends  of  the  artery.  Illustration  shows  the  finger  and  thumb  grasping  the  ad- 
ventitia from  one  end  of  the  artery  and  pulling  it  up.  This  redundant 
adventitia  is  cut  away  and  the  rest  then  retracts,  leaving  a  clear-cut  margin 
of  the  artery.  Both  ends  are  treated  in  a  similar  manner. 

Any  remaining  clots  in  the  vessel  are  stripped  out  with 
the  thumb  and  finger  and  the  end  is  held  firmly  between 
the  thumb  and  finger  of  the  left  hand  and  sponged  with 
dry  gauze  (Fig.  18).  As  the  artery  is  collapsed  and  its 
end  held  between  the  finger  and  thumb  the  gauze  cannot 


56 


SURGERY    OF    THE    BLOOD-VESSELS. 


touch  the  intima  but  merely  wipes  the  wounded  portion 
and  so  removes  any  excess  of  thrombokinase.  The  tip  of 
a  finger  of  the  right  hand  is  then  dipped  in  white  vaseline 
and  the  end  of  the  artery  is  smeared  over  with  vaseline 


Fig.  18. — The  thumb  and  finger  of  the  left  hand  grasp  the  end  of  the  artery  cfter 
the  adventitia  has  heen  removed  and  a  finger  of  the  right  hand  anoints  the 
collapsed  end  with  vaseline. 

immediately  after  being  sponged.  This  serves  to  keep 
back  any  further  juices  from  the  severed  artery  and  also 
prevents  drying  of  the  intima.  The  other  end  of  the 
vessel  is  treated  in  the  same  manner. 

All  of  these  manipulations  are  done  rapidly  for  it  is 
essential  to  complete  the  suturing  as  quickly  as  possible 
after  the  intima  has  been  exposed.  One  of  the  sutures 
which  has  been  prepared  as  directed  is  inserted  from 
without  inward  at  one  end  of  the  artery  and  from  within 
outward  at  the  other  end.  An  artery  is  quite  tough  and 
a  small  bite  will  be  sufficient.  If  too  much  is  taken,  the 
intima  cannot  be  properly  everted.  The  first  loop  of 
a  knot  is  tied,  bringing  the  ends  of  the  vessel  together. 
The  second  loop  of  the  knot  is  tied  while  holding  the  ends 


TECHNIQUE    OP    SUTURING    BLOOD-VESSELS.  .)/ 

of  the  suture  taut,  running  the  knot  down  in  this  manner 
to  prevent  the  first  loop  from  slipping.  After  tying  this 
suture,  the  arterial  suture  staff  is  placed  under  the  artery 
with  the  short  shaft  pointing  toward  the  operator.  The 


guy  suture  is  fastened  by  wrapping  it  two  or  three  times 
around  the  lowest  button  on  the  long  shaft,  and  is  cut 
short  (Fig.  19).  The  length  of  the  suture  from  the  but- 
ton to  the  vessel  should  be  about  half  an  inch.  The  sec- 
ond suture  is  placed  about  one-third  of  the  way  around 


58 


SURGERY    OF    THE    BLOOD-VESSELS. 


the  circumference  of  the  vessel  and  should  be  on  the  side 
away  from  the  operator.  The  suture  staff  can  be  laid 
flat  so  that  the  short  shaft  is  not  in  the  way  and  the  ves- 
sel ends  can  rest  upon  the  long  shaft,  thus  making  it 


Fig.  20. — The  handle  of  the  arterial  suture  staff  is  depressed  away  from  the  operator 
and  the  short  shaft  may  be  turned  flat  and  caught  so  as  to  manipulate  the  ends 
of  the  artery  into  a  more  convenient  position  for  inserting  the  second  suture. 
The  second  suture  is  inserted,  tied,  and  wrapped  around  one  of  the  upper 
buttons  on  the  long  shaft. 

easier  to  insert  the  second  suture  (Fig.  20).  The  second 
suture  is  inserted  and  tied  in  the  same  manner  as  the 
first  and  is  wrapped  around  one  of  the  upper  buttons  on 
the  long  shaft.  The  threaded  end  is  left  long  for  future 
suturing  but  the  other  end  is  cut  close  to  the  button.  As 


TECHNIQUE    OF    SUTURING    BLOOD-VESSELS.  59 

two  guy  sutures  are  now  fixed  to  the  long  shaft,  the  third 
one  is  easily  inserted  by  raising1  up  the  long'  shaft  when 
the  point  of  insertion  of  the  third  suture  is  indicated  by 
the  retraction  of  the  margins  of  the  artery.  The  needle 


Fig.  21. — The  threaded  end  of  this  guy  suture  is  left  long  for  future  suturing.  The 
unthreaded  end  is  cut  short.  The  vessel  can  now  be  lifted  on  the  staff  when 
the  apex  of  the  retracted  margins  will  indicate  the  point  for  insertion  of  the 
third  guy  suture.  This  staff  makes  the  insertion  of  the  second  and,  particu- 
larly, the  third  guy  suture  much  easier. 

is  inserted  at  the  apex  of  the  retracted  margin  (Fig.  21). 
After  this  suture  is  tied,  the  short  shaft  is  slightly  com- 
pressed toward  the  long  shaft  and  this  guy  suture  is 
wrapped  around  one  of  the  buttons  on  the  end  of  the 


short  shaft  (Fig.  22). 


The  threaded  end  is  left  long  and 


60 


SURGERY    OF    THE    BLOOD-VESSELS. 


l-Mg.  22. — After  insertion  of  the  third  guy  suture,  it  is  tied  in  the  usual  manner.  a'il 
sutures  being  about  equidistant.  The  suture  staff  is  then  grasped  by  the 
handle  in  the  manner  indicated  in  this  drawing,  and  the  short  shaft  is  slightly 
compressed  toward  the  long  shaft.  While  held  in  this  position,  the  third  guy 
suture  is  wrapped  around  one  of  the  buttons  on  the  end  of  the  short  shaft. 


TECHNIQUE    OF    SUTURING    BLOOD-VESSELS.  ()1 

the  unthreaded  end  is  cut  close,  as  in  the  second  suture. 
It  is  important  to  have  no  unnecessary  ends  hanging 
loose.  The  short  shaft  is  released  and  the  spring  makes 
tension  on  the  margins  of  the  artery,  converting  its  cir- 


cumference  into  a  triangle,  and  everting  the  intima  (Fig. 
23). 

The  three  guy  sutures  are  inserted  in  the  same  way 
when  an  artery  is  joined  to  a  vein  of  much  larger  caliber 
as  when  a  divided  artery  is  united.  Sometimes  it  is  a 


SURGERY    OF    THE    BLOOD-VESSELS. 


little  more  difficult  when  a  small  artery  is  sutured  to  a 
large  vein,  but  after  the  guy  sutures  are  once  inserted, 
the  rest  of  the  procedure  is  identical  whether  vessels  of 
equal  or  unequal  caliber  are  to  be  united. 


Fig.  24. — The  handle  of  the  staff  is  upright  and  the  whole  instrument  is  lifted  up 
so  as  to  increase  the  eversion  of  the  intima.  The  continuous,  double  mat- 
tress, or  cobbler's  stitch,  is  begun  by  using  the  threaded  ends  of  the  last  two 
guy  sutures.  The  needles  are  thrust  through  the  margins  of  the  artery  near 
the  second  guy  suture  and  should  be  inserted  at  right  angles  to  each  other 
so  they  can  be  handled  better.  The  suturing  in  this  third  is  done  toward  the 
operator,  that  is,  from  the  second  to  the  third  guy  suture. 

We  now  have  two  needles  from  the  two  guy  sutures  last 
inserted.  A  needle  is  taken  in  each  hand  and  thrust 
through  both  margins  of  the  artery  in  the  region  where 
the  second  suture  was  tied.  The  threaded  needle  from 
the  third  guy  suture  at  the  end  of  the  short  shaft  will,  of 


TECHNIQUE  OF  SUTURING  BLOOD-VESSELS. 


course,  carry  a  little  loop  of  thread  which  is  of  no  conse- 
quence. The  instrument  is  lifted  up  so  as  to  elevate  the 
upper  third  of  the  wound  and  increase  the  eversion.  The 
suture  is  then  applied  in  the  manner  of  the  double  mat- 
tress, or  cobbler's  stitch,  going  from  the  second  guy 
suture  to  the  third  (Fig.  24).  At  the  angles  particular 


Fig.  25. — The  handle  of  the  staff  is  depressed  until  it  is  horizontal  and  points  away 
from  the  operator.  Then  the  whole  instrument  is  shoved  toward  the  operator 
so  as  to  increase  the  eversion  in  the  second  third.  The  suturing  is  continued 
as  a  cobbler's  stitch. 

care  should  be  taken  to  go  beneath  the  insertion  of  the 
guy  sutures;  otherwise,  the  tension  of  the  guy  sutures 
may  produce  a  wound  in  the  endothelium  which  would  be 
exposed  to  the  lumen  of  the  vessel.  After  the  first  third 


64  SURGERY    OP    THE    BLOOD-VESSELS. 

lias  been  sutured,  the  handle  of  the  instrument  is  de- 
pressed away  from  the  operator  and  the  instrument 
shoved  toward  the  operator  so  as  to  increase  the  eversion 
of  this  third  of  the  margin  of  the  vessel  (Fig.  25).  The 
suturing  is  continued  as  a  cobbler's  stitch.  When  the 


Fig.  26. — The  handle  of  the  staff  is  then  brought  over  to  a  horizontal  position 
pointing  toward  the  operator.  The  instrument  is  lifted  tip  so  as  to  increase 
the  eversion  of  the  last  third.  The  suturing  is  continued  toward  the  second 
guy  suture. 

second  third  is  finished,  the  instrument  is  brought  to  its 
original  position  and  each  needle  carried  under  the  vessel 
so  as  to  be  ready  for  suturing  the  last  third.  The  handle 
is  then  depressed  toward  the  operator  and  held  in  such  a 
manner  as  to  lift  up  the  last  third  and  so  increase  its 
eversion  (Fig.  26).  The  suturing  is  continued  through 


TECHNIQUE    OF    SUTURING   BLOOD-VESSELS.  UO 

the  last  third  and  when  this  is  finished  the  instrument  is 
brought  back  to  its  original  position  and  the  suturing  car- 
ried about  two  stitches  beyond  the  point  of  commence- 
ment, where  the  threads  are  tied  to  each  other.  Each 
stitch  must  be  drawn  snugly  when  it  is  placed,  else  the 
intima  will  not  be  securely  approximated  and  there  will 
be  leakage.  In  the  carotid  of  a  dog  of  medium  size 
about  five  stitches  are  put  in  each  third  of  the  artery. 

Sometimes,  particularly  in  old  dogs,  retraction  of  the 
ends  of  the  artery  is  marked  and  the  sutures  cannot  be 
properly  placed  as  they  will  tend  to  cut  out  or  break 
under  the  tension.  If  the  adventitia  of  the  vessel  is 
grasped  with  curved  mosquito  forceps  about  one  and  one- 
half  inches  from  the  severed  ends,  the  two  ends  of  the 
vessel  can  be  shoved  together  by  an  assistant  without 
tension  on  the  sutures  and  without  his  hands  being  in 
the  way  of  the  operator.  This  is  better  than  trying  to 
approximate  the  ends  by  the  serrefine  clamps  which  may 
either  come  off  or  loosen  and  flood  the  vessel  with  blood. 
After  the  suturing  has  been  completed,  the  short  shaft  is 
slightly  compressed  toward  the  main  shaft  so  as  to  relax 
the  tension  on  the  guy  sutures  and  the  distal  clamp  on 
the  vessel  is  slowly  released  (Fig.  27).  If  there  is 
marked  spurting  at  any  point,  an  extra  suture  should  be 
placed  there.  With  a  little  experience  spurting  rarely 
occurs,  though  there  is  usually  oozing  of  a  few  drops  of 
blood.  The  guy  sutures  are  then  cut  and  the  instrument 
is  removed.  The  sutured  vessel  is  very  gently  com- 
pressed with  dry  gauze  and  the  distal  clamp  is  entirely 
removed.  After  about  a  minute  the  proximal  clamp  is 
slowly  removed.  In  this  time  the  needle  holes  should  be 
plugged  with  fibrin  and  there  should  be  no  leakage.  The 
vessel  must  not  be  returned  to  its  bed  until  leakage  has 
ceased.  The  whole  procedure  of  suturing  the  vessel, 


66 


SURGERY    OF    THE    BLOOD-VESSELS. 


Helen    korrarn*.    i*f. 


Fig.  27. — The  handle  of  the  instrument  is  brought  to  a  vertical  position  and,  the 
suturing  having  been  carried  about  two  stitches  beyond  its  point  of  com- 
mencement, the  threads  are  tied  to  each  other.  The  distal  clamp  is  slowly 
removed  and  the  staff  somewhat  compressed  so  as  to  relax  the  guy  sutures  and 
demonstrate  if  there  is  any  spurting  point  along  the  suture  line.  After  a 
minute,  the  other  clamp  is  removed,  and  if  no  spurting  exists  the  guy  sutures 
are  cut.  If  any  spurting  does  occur,  the  clamps  can  be  reapplied  and  an 
extra  stitch  taken  at  the  spurting  point.  With  a  little  practice,  however,  this 
is  rarely  necessary. 


TECHNIQUE    OF    SUTURING    BLOOD-VESSELS.  67 

from  the  insertion  of  the  guy  sutures  to  the  last  stitch, 
can  easily  be  done  in  from  ten  to  fifteen  minutes  and 
often  in  less  time.  Any  competent  surgeon  who  trios  this 
technique  experimentally  a  few  times  can  master  it. 

This  method  has  been  mentioned  in  several  journals. - 
The  arterial  suture  staff  has  not  been  altered  and  the 
general  principle  of  approximating  the  intima  has  always 
been  adhered  to.  However,  several  details  of  applying 
this  principle  have  been  changed,  and  it  is  the  author's 
opinion  that  these  changes  acid  to  the  value  of  the 
technique.  The  staff  holds  the  vessels  so  that  the  edges 
are  everted  and  each  stitch  is  inserted  under  the  same 
tension  from  the  first  to  the  last.  It  greatly  facilitates 
the  suturing  and  makes  possible  the  carrying  out  of 
the  principles  that  have  already  been  noted.  The  ar- 
terial suture  staff  not  only  renders  easier  the  placing 
of  the  last  two  guy  sutures,  but  holds  all  of  them  in 
proper  position  and  under  uniform  tension  throughout 
the  operation.  By  means  of  this  instrument  the  tension 
is  kept  even  at  all  points  along  the  arterial  wound. 
There  are  no  long  ends  of  sutures  to  become  entangled 
and  there  is  no  necessity  for  several  changes  with  the 
alternate  increase  and  relaxation  of  tension  when  the 
sutures  are  handled  in  the  ordinary  way,  which  neces- 
sarily interferes  with  the  regularity  and  accuracy  of  the 
suturing.  Any  one  can  hold  it;  an  assistant  trained  in 
blood-vessel  surgery  is  not  needed. 

The  changes  are  as  follows : 

1.  A  double  mattress  or  cobbler's  stitch  is  now  used 
instead  of  the  single  mattress  stitch  as  originally  ad- 
vised. It  was  found  that  when  the  single  mattress  stitch 
was  used  there  were  points  between  sutures  with  but 

2  Annals  of  Surgery,  February,  1912;  Journal  A.  M.  A.,  July  6,  1912,  and 
December  14,  1912;  Surgery,  Gynecology  &  Obstetrics,  May,  1914. 


68  SUEGERY    OF    THE    BLOOD-VESSELS. 

little  compression  and  no  raw  surface.  This  sometimes 
made  a  small  amount  of  leakage  that  was  difficult  to  con- 
trol; also  a  little  diverticulum  would  be  formed  that  was 
a  weak  spot  and  would  occasionally  result  in  secondary 
hemorrhage.  The  double  mattress  stitch  does  away  with 
these  objections  and  approximates  the  iiitiina  firmly  as 
by  a  fine  clamp  around  the  entire  margins  of  the  vessel; 
at  the  same  time  it  exposes  no  more  thread  in  the  lumen, 
than  is  exposed  by  the  single  mattress  stitch.  The  use 
of  this  stitch  can  be  readily  acquired  by  any  one  who 
tries  it.  It  has  been  most  successfully  used  in  intesti- 
nal suturing  by  Crile,  and  is  much  more  needed  in  ves- 
sel suturing,  as  there  is  more  pressure  in  a  blood-vessel 
than  in  the  bowel.  As  the  operator  must  use  both 
hands  while  inserting  the  cobbler's  stitch,  it  would  be 
difficult  to  place  this  stitch  evenly  and  satisfactorily  with- 
out the  suture  staff,  as  the  three  guy  sutures  would  have 
to  be  manipulated  by  hand. 

2.  No  salt  solution  is  now  used  to  wash  out  the  vessels. 
It  has  been  the  object  of  this  technique  to  eliminate  as 
far  as  possible  every  procedure  that  is  not  essential  to 
success.     Washing  out  the  ends  of  the  vessel  with  salt 
solution  not  only  adds  somewhat  to  the  trauma  of  the 
endothelium,  makes  a  sloppy  wound,  and  prolongs  the 
procedure,  but  according  to  Guthrie,  rather  tends  to  in- 
crease clotting  than  diminish  it. 

3.  In  order  to  strengthen  the  second  and  third  guy 
sutures  both  ends   of  these   sutures   are  now  wrapped 
around   the  buttons,   instead   of  merely  using   the   un- 
threaded ends,  as  was  formerly  advised.     Instead  of  first 
inserting  the  guy  sutures  and  then  placing  them  on  the 
suture  staff,  it  is  better  to  fix  them  on  the  staff  as  they 
are  inserted.     This  not  only  relieves  the  necessity  of 
handling  the  sutures  twice,  when  once  will  do,  but  it  is 


TECHNIQUE    OF    SUTURING    BLOOD-VESSELS.  ()(J 

much  easier  to  place  the  second  and  third  sutures  when 
the  first  has  been  fastened  to  the  staff,  as  the  staff  can 
then  be  so  maniuplated  as  to  bring  the  margins  of  the 
vessel  wound  into  a  more  advantageous  position  for 
suturing. 

The  technique  as  described  is  quite  simple  and  the  serv- 
ices of  a  trained  assistant  are  not  needed.  It  can  be 
acquired  as  readily  as  the  technique  of  suturing  in- 
testines. Dr.  E.  L.  Caudill,  an  intern  at  St.  Elizabeth's 
Hospital,  Richmond,  Va.,  who  had  never  done  an  opera- 
tion, but  merely  assisted  in  a  few  surgical  operations 
on  patients  and  in  suturing  arteries  on  animals,  divided 
the  carotid  artery  of  a  dog  and  united  it  by  this  technique 
three  times.  This  was  done  without  any  assistance  ex- 
cept that  of  a  medical  student  and  of  the  orderly  who 
gave  the  anesthetic.  Xo  one  else  was  present.  Of  the 
three  operations  two  of  them  were  successful  and  showed 
a  lumen  free  from  any  thrombus  two  weeks  and  six 
weeks,  respectively,  after  the  operation.  The  third  oper- 
ation was  unsuccessful,  as  the  artery  was  occluded  by 
thrombus.  He  undertook  experimental  work  on  suturing 
intestines  and  according  to  his  own  expression  found  it 
much  more  difficult  to  unite  a  divided  bowel  successfully 
than  to  unite  a  divided  artery.  There  seems  no  reason 
why  surgeons  who  are  likely  to  need  the  technique  of 
blood-vessel  surgery  should  not  easily  acquire  it. 

The  transplantation  of  a  segment  of  a  vein,  or  of  an 
artery,  or  of  a  rubber  tube  involves  the  same  technique 
as  suturing  a  divided  vessel.  It  is  best,  however,  to 
have  two  arterial  suture  staffs  instead  of  one.  Three 
guy  sutures  should  be  placed  at  one  end  but  only  the  first 
two  fastened  to  the  staff.  Then  the  other  end  of  the 
transplant  can  be  sutured  with  another  staff  in  the  usual 
way.  After  this  is  completed,  the  first  staff  is  taken  up, 


70  SURGERY    OF    THE    BLOOD-VESSELS. 

the  third  guy  suture  fastened  to  the  end  of  the  short 
shaft,  and  the  suturing  completed.  In  this  way  there  is 
no  inconvenience  from  the  presence  of  two  suture  staffs 
in  the  wound  at  the  same  time,  but  if  all  three  guy  sutures 
were  placed  in  position  on  the  first  suture  staff,  the  short 
end  of  the  staff  would  project  so  as  to  interfere  with 
the  suturing  at  the  second  suture  staff.  A  transplant  can 
be  taken  either  from  a  vein  or  artery,  or  a  piece  of  rubber 
tubing  can  be  used.  For  practical  purposes  the  vein  is 
best.  In  experimental  work  the  external  jugular  of  the 
dog  is  the  most  suitable  vein  to  transplant.  It  is  readily 
accessible,  is  large,  and  has  but  few  branches.  Trans- 
plantation after  resection  of  the  carotid  is  more  likely  to 
be  successful  in  experimental  work  than  transplanting  in 
the  femoral  because  the  neck  is  much  less  likely  to  be  in- 
fected than  the  leg.  This  has  been  pointed  out  by 
Watts. 

Some  attention  must  be  given  to  securing  a  section  of 
the  vein  that  is  to  be  transplanted.  The  saphenous  is 
the  best  vein  to  use  as  a  transplant  in  man.  The  vein 
must  be  exposed  and  handled  gently.  A  much  longer 
portion  should  be  taken  than  is  supposed  to  be  necessary 
for  it  contracts  greatly  after  being  removed  and  it  is  a 
simple  matter  to  cut  off  any  excess  if  it  is  too  long.  The 
vein  should  be  dissected  free  while  it  is  distended  with 
blood  and  the  adventitia  of  that  portion  of  the  vein 
which  is  to  be  cut  should  be  very  carefully  removed 
while  the  vein  is  distended,  otherwise  it  retracts  within 
the  adventitia  and  as  the  vein  is  exceedingly  thin, 
cleaning  away  the  adventitia  is  difficult  after  the  col- 
lapsed segment  has, been  removed.  When  the  adventitia 
has  been  sufficiently  removed,  any  pressure  that  caused 
the  vein  to  become  distended  is  released  and  a  ligature 
placed  on  the  distal  portion  of  the  vein.  The  blood  is 


TECHNIQUE    OF    SUTURING    BLOOD-VESSELS.  71 

then  gently  stripped  out  of  the  vein  and  another  ligature 
placed  at  the  proximal  end.  The  vein  is  cut  across  with 
sharp  scissors,  at  one  stroke  if  possible.  After  the  blood 
has  been  stripped  from  the  vein  it  should  be  entirely 
collapsed  and  like  a  ribbon.  When  the  end  is  cut  it 
is  sponged  with  dry  gauze  and  thoroughly  anointed 
with  white  vaseline,  as  mentioned  in  the  technique  of 
vessel  suturing  (page  56),  only  more  vaseline  should 
be  used  here.  The  other  end  is  then  divided  and  treated 
in  a  similar  manner.  The  vein  is  placed  on  a  sterile 
towel  and  should  be  used  as  quickly  as  possible.  The 
vein  should  not  be  removed  until  the  other  dissection  has 
been  completed,  so  that  suturing  of  the  vein  into  the  de- 
fect can  be  proceeded  with  at  once.  There  is  no  occasion 
for  washing  out  the  segment  of  vein  or  for  keeping  it  in 
salt  solution.  If  for  any  reason  it  is  necessary  to  keep 
the  segment  awhile,  it  may  be  placed  on  a  towel  or  piece 
of  gauze  that  has  been  wrung  out  of  salt  solution,  and 
another  piece  of  gauze  similarly  wrung  out  is  placed 
over  it.  It  is  not  necessary  for  the  salt  solution  to  be 
warm.  It  has  been  proven  that  cold  tends  to  retard 
thrombus  formation  and  segments  of  vessels  can  be 
kept  in  cold  storage  for  weeks  and  then  sutured  success- 

fully. 

The  author  has  used  experimentally  rubber  tubing  of 
various  kinds  to  replace  an  arterial  segment  (Fig.  28). 
This  in  most  instances  becomes  readily  covered  with 
tissue  that  resembles  the  adventitia  of  a  blood-vessel. 
It  is  well  known  that  rubber  when  properly  prepared  is 
very  slightly  irritating  to  the  tissues.  Dentists  make 
frequent  use  of  it.  If,  then,  adventitia  can  be  thrown 
around  the  rubber  tube  as  an  encapsulation,  it  would 
probably  support  the  blood  current  after  the  rubber  had 
degenerated.  The  high  reproductive  power  of  vascular 


72 


SURGERY    OF    THE    BLOOD-VESSELS. 


endothelium  is  frequently  observed  in  the  rapid  lining 
of  aneurisms  that  have  suddenly  enlarged,  and  it  seems 
possible  that  this  endothelium  might  cover  the  inner 
surface  of  the  rubber  tubing.  In  this  way  a  strong 
adventitia  and  an  intima  may,  possibly,  be  secured.  Ex- 
perimentally, however,  the  author  has  not  been  able  to 
obtain  such  a  result.  Though  the  tube  is  often  encapsul- 


Fig.  28. — A  piece  of  rubber  tube  sutured  in  between  the  cut  ends  of  an  artery. 
Note  the  complete  absence  of  any  sharp  margin  of  the  tube  and  the  absence 
of  thread  in  the  lumen.  This  cannot  be  done  by  the  regular  overhand  suture. 

ated  with  a  membrane  that  resembles  adventitia,  its  in- 
ternal surface  has  so  far  been  invariably  blocked,  sooner 
or  later,  by  thrombus.  Tubes  have  varied  from  thick, 
black  rubber  to  very  thin  rubber,  and  have  been  coated 
with  vaseline  or  paraffin.  While  it  would  be  impossible 
to  suture  tubes,  especially  thick  tubes,  by  the  overhand 
stitch,  and  at  the  same  time  make  an  accurate  approx- 
imation and  avoid  sharp  edges  of  the  tube  pointing 


TECHNIQUE    OF    SUTURING    BLOOD-VESSELS. 


inward,  by  using  a  mattress  suture  and  preferably  the 
double  mattress  with  the  staff  that  has  been  described, 
the  sharp  edges  are  everted.  While  so  far  the  author 
has  not  met  with  success  in  having  the  rubber  tube  re- 
main permanently  patent,  the  thrombus  formation  in 
some  instances  at  least  must  have  been  slow.  Clinic- 
ally, it  is  just  as  satisfactory  to  have  a  slowly  form- 
ing thrombus  in  a  tube  of  this  character,  which  would 


Fig.   29. 


Fig.   30. 


Fig.  29. — An  iliac  artery  of  a  dog  which  was  removed  a  few  minutes  after  suturing 
after  the  blood  had  been  turned  on  and  no  leakage  appeared.  Note  the  ever- 
sion  of  the  intima  constituting  a  flange  without  diminution  of  the  caliber. 

Fig.  30. — The  lumen  of  the  carotid  artery  of  a  medium  sized  dog.  The  blood  had 
been  allowed  to  flow  for  a  few  minutes  and  there  was  no  leakage.  Note  the 
absence  of  thread  in  the  lumen. 

permit  collateral  circulation  to  form,  as  it  is  to  have  the 
tube  remain  permanently  open  (Fig.  28). 

The  possibilities  of  using  a  rubber  tube  in  this  man- 
ner clinically  have  been  suggested  by  an  experiment  in 
which  the  author  resected  a  portion  of  the  abdominal 
aorta  of  a  dog  and  transplanted  a  piece  of  rubber  tube 


SURGERY    OF    THE    BLOOD-VESSELS. 


to  fill  the  defect.  The  portion  resected  was  below  the 
renal  arteries.  The  tube  was  a  soft,  black  rubber  tube 
coated  with  paraffin.  It  was  much  thicker  than  was 


Fig.  31. — A  segment  of  an  external  jugular  vein  which  was  sutured  in  the  place  of  a 
resected  portion  of  the  right  carotid  of  a  large  dog.  Note  the  valves  about 
the  middle  of  the  specimen  in  one  of  which  is  a  small  clot.  The  specimen  was 
dilated  at  this  point,  probably  from  the  force  of  the  blood  stream  in  overcoming 
the  valves.  Otherwise  the  intima  is  perfectly  smooth  and  the  sutures  are 
mostly  buried  from  view.  The  specimen  was  removed  63  days  after  operation. 

really  necessary,  and  the  suturing  was  more  difficult 
than  if  a  thinner  tube  had  been  used.  The  dog  was  a 
medium  sized  female  mongrel.  There  was  very  little 


TECHNIQUE    OF    SUTURIXG    BLOOD-VESSELS.  75 

leakage,  which  was  easily  controlled  by  pressure.  The 
peritoneal  tissues  were  sutured  over  the  tube  and  the 
abdominal  \vound  was  closed  in  layers.  The  dog-  made 


Fig.  32. — Specimen  of  reversal  of  circulation  in  the  neck.  The  proximal  end  of  the 
carotid  was  sutured  to  the  distal  end  of  the  external  jugular  vein  in  a  medium 
sized  dog.  This  specimen  was  removed  after  thirty-nine  days.  The  sutures 
are  distinctly  buried,  though  the  endothelium  over  them  is  still  transparent 
at  places.  The  line  of  suturing  is  smooth.  A  short  distance  from  the  line  of 
sutures  are  the  crumpled-up  valves  which  were  forced  and  broken  down  by  the 
blood  stream. 

a  satisfactory  recovery,  there  being  no  paralysis  of  the 
hind  legs.  As  function  had  apparently  not  been  inter- 
fered with  it  was  hoped  that  the  tube  had  remained 


76 


SURGERY    OF    THE    BLOOD-VESSELS. 


Fig.  33. — Photograph  of  a  specimen  in  which  a  rubber  tube  was  sutured  into  the 
defect  caused  by  excision  of  a  part  of  the  abdominal  aorta.  The  tube  was 
removed  after  six  months.  The  suturing  was  done  according  to  the  method 
recommended.  The  tube  was  completely  encapsulated,  though  it  was  occluded. 


TECHNIQUE    OF    SUTURING    BLOOD-VESSELS.  ~t 

patent.  Six  months  after  this  operation,  the  dog  ap- 
peared in  perfect  health.  The  dog  was  then  photo- 
graphed, killed  with  chloroform,  and  the  specimen  re- 
moved. The  lumen  of  the  tube,  however,  was  occluded 
with  -thrombus.  There  was  no  dilatation  nor  any  evi- 


.  ^ 


Fig.  34. — Photograph  of  a  dog:  in  which  a  portion  of  the  abdominal  aorta  was  re- 
sected and  a  rubber  tube  sutured  in  to  fill  the  defect.  The  dog  made  a  per- 
fect recovery.  The  photograph  was  taken  six  months  after  operation.  The 
dog  was  then  killed  and  the  specimen  removed.  The  tube  was  completely  en- 
capsulated' but  was  occluded.  The  occlusion  was  evidently  gradual,  as  there 
were  no  bad  symptoms  and  no  paralysis  of  the  legs.  Gradual  occlusion  which 
permits  time  for  collateral  circulation  is  clinically  as  satisfactory  as  if  the 
tube  had  remained  patent. 

dence  of  formation  of  an  aneurism.  The  outline  of  the 
tube  is  plainly  seen  in  the  photograph.  The  external 
caliber  of  the  tube  was  considerably  larger  than  the  ex- 
ternal caliber  of  the  artery.  (Figs.  33  and  34.) 

Ligation  of  the  aorta  in  man  has  been  universally  fatal. 
This  experiment  suggests  a  possible  substitute  for  liga- 
tion. 


78  SUEGERY    OF    THE    BLOOD-VESSELS. 

Lateral  and  Incomplete  Transverse  Wounds 
of  Blood-Vessels. 

The  preliminary  steps  in  suturing  lateral  or  transverse 
wounds  of  blood-vessels  are  the  same  as  those  outlined 
under  the  description  of  end-to-end  suturing.  The 
wound  should  be  a  clean  cut.  If  ragged  or  bruised,  the 
margins  are  trimmed  with  sharp  scissors.  If  a  trans- 
verse wound  involves  more  than  half  the  circumference 
of  a  vessel,  the  vessel  should  be  completely  divided  and 
then  united  by  the  end-to-end  method.  If  the  whole  cir- 
cumference is  contused  or  lacerated,  the  damaged  section 
must  be  excised,  and  if  the  ends  of  the  vessel  cannot  be 
sutured  together  without  too  much  tension,  a  transplant 
of  vein  may  be  used  (page  69). 

The  method  to  be  adopted  in  suturing  these  wounds 
depends  partly  upon  the  nature  of  the  wound,  but  largely 
upon  the  accessibility  of  the  blood-vessel.  When  pos- 
sible, the  vessel  should  be  freely  exposed  by  a  long  in- 
cision. The  adventitia  along  the  edges  of  the  wound 
should  be  trimmed  away  with  sharp  scissors,  blood-clots 
removed,  and  the  edges  of  the  wound  and  the  intima 
anointed  with  white  vaseline.  If  the  wound  is  parallel 
with  the  vessel,  it  may  be  grasped  with  the  forceps  used 
for  lateral  anastomosis  of  blood-vessels  (described  on 
page  84)  and  sutured  with  a  cobbler's  stitch,  using  fine, 
straight  needles  (No.  14  or  16)  and  fine  black  silk  steril- 
ized in  white  vaseline.  If  the  wound  is  transverse,  the 
suture  staff  (page  52)  may  be  placed  under  the  vessel,  a 
guy  suture  of  the  usual  material  is  inserted  at  one  end  of 
the  wound  and  wrapped  around  an  upper  button  on  the 
long  shaft,  and  another  guy  suture  is  placed  at  the  oppo- 
site end  of  the  wound  and  fastened  to  a  button  on  the 
short  shaft  while  it  is  being  compressed  toward  the  long 


TECHNIQUE    OF    SUTURING   BLOOD-VESSELS.  ( \) 

shaft.  When  the  short  shaft  is  released,  it  will  make  ten- 
sion on  the  wound,  and  evert  the  intima.  A  cobbler's 
stitch  can  then  be  placed  with  the  threaded  ends  of  the 
gny  sutures,  as  in  suturing  the  first  third  of  an  end-to-end 
union.  Care  should  be  taken  to  secure  the  beginning  of 
the  suture  line  by  going  well  beyond  the  wound  and  taking 
a  back  stitch.  Occasionally  a  transverse  or  a  lateral 
wound  may  be  so  inaccessible  that  neither  of  these  meth- 
ods can  be  used.  In  such  instances  a  long  guy  suture 
may  be  placed  at  each  end  of  the  wound  and  held  by  an 
assistant  while  the  wound  is  closed  with  a  continuous 
overhand  stitch  of  black  silk  in  a  curved,  round  needle  (a 
number  three  French  intestinal  needle)  sterilized  in  vase- 
line. There  will  be  more  leakage  from  the  needle-holes 
after  this  method  and  thrombosis  is  more  frequent,  but 
in  deep  wounds  it  may  be  the  only  technique  applicable. 


CHAPTER  V. 

LATERAL  ANASTOMOSIS  OF  BLOOD-VESSELS, 
AND  REVERSAL  OF  THE  CIRCULATION. 

Lateral  anastomosis  of  blood-vessels  is  used  either  in 
uniting  a  vein  to  a  vein,  as  in  the  Eek  fistula  when  the 
portal  vein  is  joined  to  the  vena  cava,  or  in  uniting  an 
artery  to  a  vein  when  it  is  desired  to  reverse  the  circu- 
lation. The  indications  for  Eck  fistula  are  few,  if  any, 
so  far  as  its  clinical  application  is  concerned.  The  op- 
eration was  described  by  Eck,  a  Russian  surgeon,  in  1877, 
and  again  in  1879.  It  has  been  performed  a  few  times 
by  German  surgeons  in  cirrhosis  of  the  liver,1  but  the 
metabolic  products  from  the  portal  circulation  sooner  or 
later  produce  a  toxic  effect  when  discharged  into  the  gen- 
eral circulation  at  a  rate  as  great  as  the  Eck  fistula  per- 
mits. Again,  it  is  possible  that  the  ascites  may  be  due  to 
irritation  of  the  peritoneum  and  not  solely  to  portal  ob- 
struction. 

The  indications  for  reversal  of  the  circulation  are  still 
under  much  dispute.  Halstead  and  Vaughan  2  reviewed 
the  literature  and  reported  personal  experience.  They 
conclude  that  the  operation  for  reversal  of  the  circula- 
tion has  no  practical  value.  Coenen,  of  Breslau,  opposes 
the  operation  and  gives  his  reasons  at  some  length. 
They  are  that  the  valves  must  be  forced,  that  it  is  prob- 
able the  arterial  blood  following  the  route  of  least  re- 
sistance goes  through  the  first  anastomotic  vein  back  to 


iRosenstein:    German    Surgical    Congress,    1912. 
2  Surgery,    Gyneeology    &    Obstetrics,    January,    1912. 

80 


LATERAL    ANASTOMOSIS REVERSAL    OF    CIRCULATION.         81 

the  heart  and  rarely  if  ever  reaches  the  terminal 
branches  of  the  vein,  that  in  arteriovenous  aneurism  it 
takes  weeks  and  sometimes  months  for  valves  to  be 
forced  sufficiently  to  detect  pulsation  in  the  smaller  veins, 
and  that  the  arterial  blood  in  venous  capillaries  must 
have  some  manner  of  return  which  has  not  yet  been  fully 
studied.  There  are  many  pathological  conditions  in  man 
such  as  arteriosclerosis,  thrombo-angeitis  obliterans, 
diabetes  and  Raynaud's  disease  that  do  not  occur  in  ex- 
perimental work.  When  the  vessel  itself  is  diseased 
at  the  site  of  the  anastomosis,  or  when  the  veins  are  in- 
volved in  the  disease,  reversal  of  the  circulation  is  use- 
less. When  gangrene  has  already  occurred,  of  course, 
operation  for  reversing  the  circulation  cannot  bring  re- 
lief. 

The  practical  utility  of  reversal  of  the  circulation  is 
doubtful.  Some  experiments  which  the  author  has  re- 
cently performed  and  which  are  not  yet  ready  for  full 
report  seem  to  show  that  in  reversal  of  the  circulation 
the  blood  returns  to  the  heart  by  anastomotic  venous 
branches  a  short  distance  below  the  site  of  the  opera- 
tion and  that  the  arterial  blood  in  a  reversed  femoral 
vein  never  reaches  the  foot  and  usually  goes  but  little 
below  the  knee. 

If  the  circulation  is  to  be  reversed,  it  should  be  done  by 
lateral  anastomosis  and  not  by  an  end-to-end  union. 
When  the  vein  and  artery  are  both  cut  across  and  the  ar- 
tery is  united  to  the  vein  end-to-end,  the  distal  channel 
of  the  artery  is  sacrificed,  whereas  if  lateral  anastomo- 
sis is  performed  and  the  vein  ligated  on  the  cardiac  side, 
there  will  be  two  channels  for  the  arterial  blood  instead 
of  one.  The  original  arterial  channel  is  not  put  out  of 
commission  and  at  least  no  harm  will  be  done  even  if  no 
good  is  accomplished.  This  was  originally  pointed  out 


82  SURGERY    OF    THE    BLOOD-VESSELS. 

by  J.  B.  Murphy  and  has  later  been  demonstrated  and  in- 
sisted upon  by  Bernlieim  and  others. 

When  the  main  artery  to  a  limb  is  partially  occluded 
and  the  veins  are  healthy,  the  arterial  blood  in  the 
capillaries  is  probably  drained  off  more  quickly  than 
normal.  Tims  the  tissues  are  not  bathed  with  arterial 
blood  sufficiently  long  to  be  nourished  properly.  Ob- 
structing a  large  vein  may  prevent  this  rapid  passage  of 
arterial  blood  and  so  equalize  the  circulation  and  improve 
the  condition  of  the  limb.  In  this  way  may  be  explained 
some  of  the  reported  improvements  that  have  followed 
reversal  of  the  circulation  in  a  limb,  particularly  after 
the  end-to-end  method.  Ligation  of  the  femoral  vein 
should  be  equally  beneficial. 

When  doing  a  lateral  anastomosis  of  artery  and  vein, 
Bernlieim  and  Stone  3  recommend  making  the  opening  in 
the  vessels  by  transfixing  them  with  a  cataract  knife  and 
cutting  from  within  out  about  one-third  of  the  circum- 
ference. The  vessels  are  then  cleaned  with  normal  salt 
or  Kinger's  solution,  anointed  with  liquid  vaseline,  and 
united  by  a  continuous  suture  of  fine  silk. 

Bernlieim  and  Boegtlin 4  discuss  the  question  of 
whether  an  Eck  fistula  is  compatible  with  life  and  de- 
scribe a  new  method  for  making  this  fistula.  The  portal 
vein  and  vena  cava  are  first  sewed  together  with  a 
small  curved  needle  and  silk,  using  a  continuous  suture 
and  No.  3  curved,  French  intestinal  needle  with  double 
thread.  Another  row  of  sutures  is  made  parallel  with 
this  and  an  especially  constructed  scissors  with  sharp 
points  is  partly  opened,  and  one  blade  plunged  into  the 
vena  cava  and  the  other  into  the  portal  vein.  The  par- 
tition is  then  cut.  A  previously  inserted  suture  is 

3  Annals  of   Surgery,    October,    1911. 

4  Bulletin    of   Johns    Hopkins    Hospital,    February,    1912,    page    33. 


LATERAL    ANASTOMOSIS REVERSAL    OF    CIRCULATION.        83 

quickly  tied  at  the  point  of  the  puncture  of  the  scissors. 
They  claim  that  Eck  fistula  in  dogs  is  consistent  with  life 
for  a  long  period  of  time  provided  the  diet  is  regulated, 
though  certain  hepatic  functions  are  decreased  when  an 
Eck  fistula  is  present,  notably,  tolerance  for  sugars,  the 
formation  of  bile,  and  the  hemolytic  function  of  the  liver. 

The  technique  of  Bernheim  is  similar  to  that  of  Sweet, 
who,  in  1904,  described  a  method  in  which  a  fine  platinum 
wire  was  passed  into  the  veins  and  an  electric  current 
connected,  after  the  two  rows  of  sutures  had  been  placed, 
so  burning  an  opening. 

The  technique  of  Carrel  and  Guthrie  involves  dissect- 
ing the  vena  cava  and  the  portal  vein  and  clamping  them 
above  and  below  the  site  of  operation,  which  is  difficult 
and  tedious.  The  union  is  made  with  straight  arterial 
needles. 

If  a  lateral  anastomosis  is  to  be  done  on  easily  accessi- 
ble vessels  the  technique  is  simple,  but  if  the  vesesls  are 
difficult  to  expose,  or  if  hemostasis  cannot  be  complete, 
it  becomes  very  trying.  In  an  effort  to  standardize  a 
technique  that  could  be  used  in  all  cases  of  lateral  an- 
astomosis, whether  in  making  an  Eck  fistula,  or  in  unit- 
ing an  artery  and  a  vein  in  a  difficult  location,  the  author 
has  devised  a  forceps  that  takes  a  lateral  hold  either 
on  the  entire  caliber  of  each  vessel,  or  on  any  portion 
of  it  as  desired.  The  necessity  for  such  a  forceps  was 
suggested  by  an  operation  done  by  the  author  at  the 
clinic  of  Prof.  "W.  L.  Rodman,  in  Philadelphia,  through 
the  courtesy  of  Prof.  Rodman.  The  case  was  an  ar- 
teriovenous  aneurism  of  the  femoral  artery  and  vein, 
too  close  to  Poupart's  ligament  for  the  application  of 
a  tourniquet.  After  dissecting  the  artery  and  vein 
above  and  below  the  aneurism,  placing  Crile  clamps  on 
these  vessels  above  and  below  the  lesion,  clamping  the 


84  SURGERY    OF    THE    BLOOD-VESSELS. 

profunda  and  controlling  the  internal  branches,  an  at- 
tempt was  made  to  dissect  behind  the  aneurism.  This 
was  difficult  and  bloody,  but  it  was  thought  that  the 
blood  was  what  remained  in  the  sac  and  tissues.  An 
incision  into  the  communication  between  the  vessels  was 
followed  by  profuse  bleeding  that  was  controlled  with 
considerable  difficulty.  It  was  suggested  by  Prof.  Rod- 
man and  by  Dr.  Stewart  Rodman,  who  kindly  assisted 
in  the  operation,  that  a  forceps  that  could  clamp  these 
vessels  before  dividing  them  would  be  advantageous. 
On  looking  up  the  matter  afterward,  the  author  found 
three  kinds  of  forceps  for  clamping  vessels  for  lat- 
eral suture.  One  was  Joani's  clamp.5  The  author  has 
never  seen  this  instrument  but  from  the  illustration  the 
points  appear  frail  and  the  handles  are  at  such  an  angle 
to  the  blades  as  to  interfere  with  suturing.  The  forceps 
of  Stewart,6  the  jaws  of  which  consist  of  large  ovals, 
could  not  be  used  in  arteriovenous  aneurism.  The  in- 
strument of  Jeger,7  a  diminutive  Roosevelt  gastro-enter- 
ostomy  clamp,  has  straight  blades  and  the  middle  blade  is 
objectionable.  It  was  devised  for  making  an  Eck  fistula. 
After  experimentation  and  several  changes  a  model  was 
devised  that  seems  to  obviate  the  objections  of  the  other 
instruments  (Fig.  35).  These  forceps  for  lateral  suture 
are  five  inches  long,  have  thin,  well-tempered  curved 
blades  with  longitudinal  grooves,  and  handles  that  extend 
in  the  axis  of  an  imaginary  line  drawn  from  the  tip  to 
the  heel  of  the  blades.  The  blades  fit  accurately  but  are 
soft  enough  to  be  clamped  on  the  skin  of  the  forearm 
without  pain.  They  can  hardly  injure  the  intima  but 
to  make  this  even  surer  soft,  pure  rubber  tubing  is 
slipped  over  the  blades.  The  tubing  should  not  be  too 

5  Keen's    Surgery,   Vol.    5,    page    128. 

c  Journal   A.   M.    A.,    August   20,    1910. 

1  Presented    at    German    Surgical    Congress,    1912. 


LATEEAL    ANASTOMOSIS REVERSAL    OF    CIRCULATION.        85 


close  to  either  the  heel  or  the  tip  of  the  blades  as  this 
might  interfere  with  the  pressure  in  the  middle  of  the 
blades  and  so  cause  leakage.  Such  forceps  can  be  used 
for  suturing  lateral  wounds  of  large  blood-vessels  without 
entirely  obstructing  the  blood-current.  In  creating  an 
Eck  fistula,  the  axis  of  the  handles  makes  it  possible  for 
the  handles  to  lie  flat  in  the  abdomen  and  so  be  out  of 
the  way.  These  forceps  can  be  used  where  no  tourniquet 


Fig.  35. — Forceps  for  lateral  blood-vessel  suturing.  They  are  made  with  very  light 
blades  which  can  be  clamped  on  the  skin  of  the  forearm  without  pain.  The 
handles  lie  in  the  axis  of  a  line  drawn  from  the  tip  to  the  heel  of  the  blades. 
In  this  way  the  handles  will  lie  flat  even  in  a  deep  wound  and  be  out  of  the 
operator's  way.  In  order  still  further  to  prevent  injury  to  the  intima,  the 
blades  may  be  covered  with  soft  rubber  tubing. 

can  be  applied,  as  on  the  iliac  vessels ;  or  in  operations  on 
an  arteriovenous  aneurism  where  hemostasis  is  not  satis- 
factory by  other  means.  Even  where  hemostasis  is  com- 
plete, they  serve  to  steady  the  walls  of  the  blood-vessel 
while  sutures  are  inserted  and  lessen  the  amount  of  in- 
tima exposed,  so  preventing  it  from  drying. 

These  forceps  have  other  uses  than  for  lateral  anasto- 
mosis, or  the  cure  of  arteriovenous  aneurism.  For  in- 
stance, they  can  be  employed  for  hemostatic  forceps  in- 
stead of  the  Crile  clamp,  acting  in  the  same  manner  as 


86  SURGERY    OF    THE    BLOOD-VESSELS. 

the  forceps  of  Matas,  which  are  designed  for  temporary 
occlusion  of  the  vessel.  As  the  blades  are  very  soft, 
they  can  be  quickly  applied  and  locked  without  fear  of 
injury  to  the  intima.  The  author  lias  also  used  the 
forceps  satisfactorily  in  a  gastro-enterostomy  in  an  in- 
fant four  weeks  old  when  an  operation  was  necessary  on 
account  of  pyloric  stenosis. 

In  lateral  anastomosis  of  blood-vessels,  whether  unit- 
ing veins  as  in  Eck  fistula,  or  an  artery  to  a  vein,  the 
same  general  principles  of  blood-vessel  suturing  men- 
tioned in  the  chapter  on  end-to-end  suture  should  be  ob- 
served (see  page  47).  Asepsis  should  be  rigid,  hemo- 
stasis  complete,  the  tissues  should  be  handled  gently,  the 
adventitia  should  be  removed,  and  after  the  intima  is 
exposed  the  operation  should  be  completed  as  quickly  as 
possible  by  uniting  intima  accurately  to  intima  and  leav- 
ing but  little  foreign  substance  or  suture  material  ex- 
posed in  the  lumen. 

The  vessels  are  exposed  as  fully  as  possible  and  are 
mobilized.  It  is  not  necessary  to  dissect  both  vessels 
entirely  free  from  their  beds,  if  they  are  close  together. 
The  adventitia  over  the  parts  of  the  vessel  to  be  incised  is 
dissected  off  and  the  lateral  clamps  described  are  applied, 
catching  a  deep  hold  on  the  vessel  wall  (Figs.  36  and 
37).  Both  are  applied  in  the  same  direction.  It  is  bet- 
ter, if  possible,  for  the  vessel  to  be  stripped  of  blood 
while  placing  the  clamps.  After  both  clamps  are  fast- 
ened, the  vessels  are  anchored  together  with  two  stay  su- 
tures of  fine  silk  sterilized  in  vaseline  and  placed  at  a  little 
distance  from  the  two  extremities  of  the  proposed  anas- 
tomotic  opening.  The  ends  should  be  left  long  and  the 
vessels  manipulated  by  these  stay  sutures  and  not  by  the 
handles  of  the  clamps  which  might  slip  or  pull  off  with 
too  much  traction.  An  incision  is  then  made  into  the 


LATERAL    ANASTOMOSIS REVERSAL    OF    CIRCULATION.         S? 


Fig.  36. — One  forceps  is  shown  covered  with  rubber  and  grasping  the  vessel  pre- 
paratory to  making  a  lateral  anastomosis.  If  it  is  deemed  unwise  to  occlude  all 
of  the  vessel,  only  a  portion  of  it  can  be  caught. 


Fig.    37. — The   two   vessels   to  be   anastomosed    have   been    clamped.      The    adventitia    is 
being  lifted   and   cut   away. 


SURGERY    OF    THE    BLOOD-VESSELS. 


vessels  (Figs.  38  and  39).  This  is  done  when  an  artery 
and  vein  are  united  by  incising  the  artery  transversely 
for  about  one-third  of  its  diameter  with  sharp  scissors 
(Fig.  39).  The  wound  retracts,  leaving  an  oval  opening, 
and  is  smeared  with  white  vaseline  by  dipping  a  finger  of 
the  left  hand  in  vaseline  and  anointing  the  wounded  ves- 


Pig.  38. — The  openings  in  the  two  vessels  are  being  made.  The  method  illustrated  in 
this  drawing  is  that  which  should  be  employed  in  an  Eck  tistula.  A  small 
point  of  the  vein  is  caught  with  the  fine  thumb  forceps,  lifted  up,  and  the  apex 
cut  away  with  scissors  parallel  with  the  vessel.  This  is  done  on  each  side 
after  the  two  stay  sutures  have  fastened  the  veins  together  near  the 
end  of  the  proposed  incision.  After  a  small  hole  has  been  cut,  a  guy  suture  is 
inserted  in  the  wall  of  the  vena  cava  on  the  operator's  left  and  is  clamped 
with  forceps  but  is  not  tied.  Another  suture  is  inserted  in  the  wall  of  the 
,  portal  vein  on  the  operator's  right  by  passing  the  needle  from  without  inward. 
The  needle  is  left  attached  but  the 'suture  is  not  tied.  By  pulling  on  these 
sutures,  the  small  openings  are  exposed  and  can  be  enlarged  as  a  slit  with 
scissors.  If  a  transverse  opening  is  made  here,  the  ends  of  the  transverse 
incision  will  retract  in  the  deep  wound. 

sel.  The  opening  in  the  vein  is  made  in  a  similar  manner 
and  should  be  slightly  larger  than  the  opening  in  the  ar- 
tery. A  fine  thumb  forceps,  or  "frog"  forceps,  holds  the 
vessel  wall  while  it  is  being  incised  and  enables  the  sur- 
geon to  make  the  opening  more  accurately.  A  tractor 
suture  of  fine  silk  sterilized  in  vaseline  is  placed  in  the 
left  margin  of  the  opening  in  the  left  vessel.  This  is  not 


LATERAL    ANASTOMOSIS REVERSAL    OF    CIRCULATTOX. 


Fig.  40. — The  two  stay  sutures  and  two  tractor  sutures  are  inserted  and  the  openings 
are  ready  for  suturing. 


90 


SURGERY    OF    THE    BLOOD-VESSELS. 


tied  but  clamped  with  mosquito  forceps.  A  similar  trac- 
tor suture  is  placed  in  tlie  right  margin  of  the  right  ves- 
sel, but  the  needle  end  is  left  attached  and  the  suture  is 
inserted  from  without  inward  (Fig.  40).  The  sewing  is 
now  begun  with  a  small  curved,  arterial  needle  (or  No.  3 
French  intestinal  needle)  and  fine  silk  sterilized  in  vase- 
line, starting  from  the  angle  of  the  incision  nearest  the 


Fig.  41. — Suturing  has  been  begun  by  using  a  very  fine  curved  needle  and  black 
silk.  It  is  started  by  going  from  without  inward  on  one  side  and  from  within 
outward  on  the  other  side.  The  thread  is  then  tied  which  leaves  the  knot  out- 
side of  the  lumen.  The  end  of  the  thread  is  caught  in  a  clamp.  The  needle 
is  then  thrust  through  the  artery  near  the  knot  and  suturing  begins  as  an  over- 
hand continuous  stitch.  It  is  important  to  have  the  knot  placed  at  the  angle 
of  the  incision. 

handle  of  the  forceps.  The  needle  is  thrust  through  the 
wall  of  the  vessel  at  the  angle,  going  from  without  in- 
ward on  one  side  and  from  within  out  on  the  other.  The 
thread  is  then  tied,  holding  the  ends  of  the  thread  taut 
while  running  down  the  second  knot  to  prevent  slipping. 
This  leaves  the  knot  outside  the  lumen.  The  short  end 
is  clamped  with  mosquito  forceps.  The  needle  is  again 
thrust  through  the  blood-vessel  wall  near  the  knot,  and  a 


LATERAL    ANASTOMOSIS REVERSAL    OF    CIRCULATION. 


continuous  overhand  suture  is  applied,  uniting  the  intiina 
accurately  (Fig.  41).  This  can  be  easily  done,  using  a 
mosquito  forceps  for  a  needle  holder  if  necessary,  and 
pulling  on  the  tractor  and  stay  sutures  as  indicated  to 
expose  the  margins  of  the  vessel  wound.  At  the  other 
angle  care  is  taken  to  place  the  sutures  closely  for  leak- 
age is  likely  to  occur  here.  After  this  angle  lias  heen 


Fig.  42. — The  suturing  is  continued  and,  after  the  upper  angle  is  readied,  the 
tractor  suture  on  the  left  is  removed  and  the  needle  and  tractor  suture  on  the 
right  thrust  through  the  margin  of  the  left  vessel.  This  is  tied  and  when 
lifted  up  brings  the  sides  accurately  together  and  renders  the  suturing  easier. 
After  the  thread  has  reached  its  original  starting  point,  it  should  be  carried 
about  one  stitch  be\  ond  the  knot  and  tied  snugly  to  the  end  that  was  clamped 
in  forceps. 

sutured,  the  left  tractor  suture  is  removed  and  the  nee- 
dle on  the  right  tractor  suture  is  thrust  through  the  wall 
where  the  left  tractor  suture  was  and  this  suture  is  then 
tied  (Fig.  42).  The  excess  of  vaseline  is  squeezed  out, 
the  tractor  suture  is  lifted  up  so  as  to  evert  the  intiina, 
and  the  sewing  is  continued  as  an  overhand  stitch. 
When  the  original  knot  in  the  continuous  suture  is 
reached,  about  one  stitch  is  taken  beyond  it  and  the 


92 


SURGERY    OF    TTTE    BLOOD-VESSELS. 


Fig.  43. — The  lateral  anastomosis  is  completed.  The  technique  is  practically  the  same 
for  an  Eck  fistula  or  an  arteriovenous  anastomosis  except  as  shown  in  Figs 
38  and  39. 


Fig.  44. — Drawing  of  a  specimen  of  an  Eck  fistula  in  a  dog  six  days  after  the  opera- 
tion.    There  is  no  thrombosis.      Magnified  about  three  times. 


LATERAL    ANASTOMOSIS REVERSAL    OF    CIRCULATION. 


thread  tied  to  the  end  that  was  left  clamped  in  mosquito 
forceps  (Fig.  43).  The  clamp  from  the  vein  is  first 
slowly  removed  and  the  line  of  suturing  slightly  com 
pressed  with  dry  gauze.  After  a  minute  the  arterial 
clamp  is  slowly  relaxed  and  then  removed  if  no  marked!) 
spurting  point  occurs.  If  it  does,  the  clamp  is  reapplied 
and  a  suture  placed  at  the  spurting  point.  A  ligature 


Fig.  45. — Lateral  anastomosis  between  the  carotid  artery  and  external  jugular  vein 
in  a  dog.  Note  the  clear  opening  and  .just  below  the  opening  a  valve  in  the 
vein.  Drawing  magnified  about  three  times.  Specimen  was  removed  twenty- 
one  days  after  the  operation. 

is  put  on  the  cardiac  side  of  the  vein  to  prevent  the 
blood  being  immediately  returned  to  the  heart  (Figs.  44 
and  45). 

In  creating  an  Eck  fistula,  this  same  technique  is  fol- 
lowed except  in  incising  the  blood-vessels  it  was  found 
that  a  transverse  incision  was  not  practical  in  large,  thin 
vessels  in  such  a  deep  wound,  for  it  was  difficult  to  su- 
ture the  deepest  portion  of  the  transverse  incisions. 


9-1  SURGERY    OP    THE    BLOOD-VESSELS. 

The  opening  in  the  veins  is  made  as  follows :  A  very 
small  bite  of  the  vena  cava  about  the  middle  of  the  pro- 
posed incision  is  caught  with  the  ' '  frog ' '  forceps  or  with 
mosquito  forceps  and  pulled  up  to  form  a  cone  whose 
apex  grasped  in  the  forceps  is  cut  oft'  with  curved  scis- 
sors (Fig.  38).  A  tractor  suture  is  inserted  in  the  outer 
wall  of  this  small  opening  in  a  similar  manner  as  in 
arteriovenous  anastomosis.  The  same  procedure  is  car- 
ried out  on'  the  portal  vein  and  a  tractor  suture  inserted 
from  without  inward  and  the  needle  left  attached.  These 
openings  are  then  enlarged  longitudinally  as  far  as  de- 
sired. The  rest  of  the  technique  is  followed  exactly  as 
described  for  arteriovenous  anastomosis.  It  is  possi- 
ble, however,  to  use  successfully  a  coarser  needle  and 
thread  in  Eck  fistula  than  in  arteriovenous  anastomosis 
as  the  pressure  is  very  low  in  the  large  veins. 


CHAPTER  VI. 
TRANSFUSION  OF  BLOOD. 

One  of  the  applications  of  blood-vessel  surgery  is 
transfusion  of  blood.  This  operation,  which  consists  in 
transferring  blood  from  the  vessels  of  one  animal  or  per- 
son to  those  of  another,  is  very  old,  though  the  earlier 
methods  of  performing  it  were  far  from  successful. 
References  to  it  are  found  in  the  Metamorphoses  of  Ovid, 
where  the  sorceress,  Medea,  took  blood  from  healthy 
young  men,  mixed  it  with  certain  juices  from  vegeta- 
bles, and  then  injected  the  mixture  into  the  veins  of  old 
men  who  desired  to  renew  their  youth.  The  ancient 
Egyptians  alluded  to  transfusion  in  their  writings  and 
probably  practiced  it.  "The  Book  of  Wisdom"  of  Tana- 
quila,  the  wife  of  Tarquin,  refers  to  transfusion.  It  is 
also  mentioned  in  the  sacred  book  of  the  priests  of 
Apollo,  and  in  the  works  of  Pliny  and  of  Celsus. 

The  earliest  authentic  case  on  record  occurred  in  1492, 
when  according  to  Villari's  "Life  of  Savonarola,"  Pope 
Innocent  VIII  was  transfused.  He  had  fallen  into  a  coma 
and  could  not  be  aroused.  The  blood  of  the  pope  was 
passed  into  the  veins  of  a  youth,  "whose  blood  was  trans- 
ferred into  those  of  the  old  man.  The  experiment  was 
tried  three  times,  and  at  the  cost  of  the  lives  of  the  three 
boys,  probably  from  air  getting  into  their  veins,  but  with- 
out any  effect  to  save  that  of  the  pope." 

Libavius  advocated  arterial  transfusion  by  silver  tubes 
as  early  as  1615. 

95 


96  SURGERY    OF    THE    BLOOD-VESSELS. 

Giovanni  Colle,  of  Padua,  in  16-8,  mentioned  transfu- 
sion as  a  means  of  prolonging  life. 

In  1665  Lower,  of  Oxford,  bled  animals  to  the  point 
of  syncope  and  then  revived  them  by  the  injection  of 
blood  from  other  animals.  His  results  were  published 
two  years  later.  He  used  a  quill  to  connect  the  artery 
of  the  donor  to  the  vein  of  the  recipient. 

In  the  celebrated  diary  of  Samuel  Pepys  is  a  note  under 
date  of  November,  1666,  in  which  transfusion  of  blood  in 
dogs  is  described,  one  dog  being  almost  bled  to  death  and 
then  transfused  from  another.  Pepys  says,  "This  noon 
I  met  with  Mr.  Hooke,  and  he  tells  me  the  dog  which  was 
filled  with  another  dog's  blood,  at  the  college  the  other 
day,  is  very  well  and  like  to  be  as  ever,  and  doubts  not  its 
being  found  of  great  use  to  men ;  and  so  did  Dr.  Whistler, 
who  dined  with  us  at  the  tavern. ' ' 

In  1667,  Denys,  of  France,  repeated  the  experiments  of 
Lower.  He  also  transfused  a  fever  patient  with  ten 
ounces  of  lamb's  blood,  and  the  patient  recovered.  He 
treated  an  insane  patient  by  injecting  several  ounces  of 
calf's  blood  and  recovery  from  the  insanity  was  reported. 
However,  three  months  afterwards  the  disease  recurred 
and  Denys  attempted  to  open  the  vein  in  the  patient's 
arm,  but  found  no  blood.  The  patient  promptly  died  and 
his  wife  accused  the  surgeon  of  killing  her  husband  and 
the  surgeon  accused  the  wife  of  poisoning  her  husband. 
There  was  considerable  excitement  in  Paris  as  a  result  of 
the  case  and  the  operation  was  very  much  discredited. 
Finally,  a  law  was  passed  which  practically  forbade  the 
performance  of  transfusion. 

In  1667,  a  German  surgeon,  Mayer,  performed  trans- 
fusion of  blood.  Kaufmann  and  Purmann,  in  1683, 
claimed  to  have  cured  a  leper  by  the  repeated  injections 
of  lamb's  blood. 


TRANSFUSION    OF    BLOOD.  97 

In  1682,  Ettenmuller,  of  Leipsic,  advised  transfusion 
in  fevers,  scurvy,  and  hypochondriasis.  Xuck  seems  to 
have  had  advanced  views  on  transfusion.  In  1714,  he 
gave  a  history  of  transfusion  in  his  book,  advocating  the 
employment  of  this  operation  when  considerable  blood 
had  been  lost,  and  advising  against  the  use  of  blood  of 
lower  animals  when  transfusing  man. 

In  1749,  Cantwell,  of  the  Faculty  of  Paris,  said  trans- 
fusion should  not  be  forbidden  in  desperate  cases. 

Michael  Rosa,  in  1783,  made  experiments  in  transfu- 
sion with  lower  animals  and  concluded  that  transfusing 
blood  from  one  animal  to  another  of  the  same  species 
could  be  done  without  danger  to  life  and  that  an  exsan- 
guinated animal  could  be  revived  by  this  means. 

About  this  time,  Laine  claimed  that  the  blood  of  calves 
and  animals  contained  some  material  that  was  necessary 
for  the  development  of  peculiar  tissues,  such  as  horn 
and  hoofs,  which  belong  to  these  animals  and  therefore 
these  elements  would  be  disastrous  when  injected  into 
the  veins  of  a  human  being. 

Harwood,  in  Cambridge,  resuscitated  an  exsanguin- 
ated dog  by  transfusion  in  1792,  and  in  the  same  year  it 
is  reported  that  Eussell  successfully  transfused  for  hy- 
drophobia with  lamb's  blood. 

In  1796,  Darwin  advised  transfusion  in  certain  dis- 
eases when  proper  nutrition  was  difficult. 

In  1802,  Scheele  wrote  an  extensive  review  on  trans- 
fusion and  Diefenbach  published  an  article  reviewing 
transfusion  in  1828. 

In  1825,  James  Blundell,  of  London,  revived  the  opera- 
tion. He  experimented  on  dogs  by  first  bleeding  them 
until  pulse  and  respiration  had  ceased  and  then  transfus- 
ing with  fresh  blood.  He  demonstrated  that  animals 
which  were  apparently  dead  for  three  or  four  minutes 


98  SURGERY    OF    THE    BLOOD-VESSELS. 

could  be  resuscitated  by  transfusion,  but  transfusion  was 
of  no  avail  after  five  minutes.  His  work  greatly  stim- 
ulated interest  in  transfusion.  Blundell's  transfusions 
upon  man  were  not  as  successful  as  those  performed  on 
the  lower  animals.  His  first  cases  all  failed  but  after- 
wards he  met  with  considerable  success. 

Dumas  and  Prevost,  in  1825,  first  showed  the  injurious 
effect  of  the  blood  of  one  species  upon  that  of  another. 
About  1838,  Bishoff  introduced  defibrination  of  blood  for 
transfusion  and  concluded  that  venous  blood  is  harmful 
but  arterial  blood  is  free  from  danger. 

Panum  and  Brown-Sequard,  in  1858,  performed  nu- 
merous experiments  independently  and  both  came  to  the 
conclusion  that  defibrination  of  the  blood  was  one  of  the 
chief  factors  in  the  success  of  transfusion. 

In  1863,  Blasius  collected  one  hundred  and  sixteen 
transfusions,  all  that  had  been  done  in  the  previous  forty 
years.  Fifty-six  of  these  were  reported  as  having  re- 
sulted favorably.  All  were  indirect  transfusions  and  only 
two  were  from  animals,  though  those  two  are  said  to  have 
been  successful.  Of  the  fourteen  cases  in  this  series  that 
were  done  with  undefibrinated  human  blood  all  were  fail- 
ures. From  the  time  of  publication  of  this  article  until 
1883,  when  von  Bergmann  published  a  paper  on  transfu- 
sion, this  operation  excited  a  great  deal  of  interest. 
Transfusion  of  blood  was  tried  indiscriminately,  and 
Emerson  in  "Works  and  Days,"  in  1870,  refers  to  it 
as  "the  boldest  promiser  of  all,  which  in  Paris,  it  is 
claimed,  enables  a  man  to  change  his  blood  as  often  as 
his  linen." 

In  the  Franco-Prussian  War  thirty-seven  transfusions 
of  defibrinated  human  blood  were  recorded  and  thirteen 
of  these  were  reported  to  be  successful.  Geselius  and 
Hasse,  in  1874  and  1875,  attempted  to  revive  transfusion 


TRANSFUSION    OF   BLOOD.  99 

of  blood  from  animals  to  human  beings.  Lamb's  blood 
was  supposed  to  be  particularly  efficacious  because  the 
red  blood  cells  are  smaller  than  those  of  man.  When 
Landois  discovered,  in  1875,  that  red  blood  cells  are  de- 
stroyed when  mixed  with  blood  of  a  different  species, 
further  attempts  at  transfusion  from  lower  animals  to 
man  were  abandoned. 

By  1889,  the  opinion  was  generally  held  that  it  was 
exceedingly  dangerous  to  inject  the  blood  from  one  spe- 
cies of  animals  into  another.  More  modern  work  lias 
confirmed  this  idea. 

Landois  and  others  showed  that  blood  from  the  same 
species  might  be  transfused  without  destruction  of  the 
cells  and  that  the  blood  would  functionate  normally.  It 
began  to  be  recognized  that  defibrinated  blood  was  not 
free  from  danger  and,  in  1877,  A.  Koehler  showed  that 
the  intravenous  injection  of  defibrinated  blood,  even  in 
animals  of  the  same  species,  might  cause  clotting  within 
the  vessels  because  of  the  large  amount  of  fibrin  ferment 
contained  in  defibrinated  blood.  Cohnheim  claimed  that 
the  injection  of  any  blood  in  which  coagulation  had  taken 
place  was  a  grave  error. 

In  1883,  von  Bergmann  reviewed  transfusion  of  blood 
and  came  to  the  conclusion  that  only  direct  transfusion 
of  blood  from  artery  to  vein  was  justifiable  and  here  co- 
agulation was  likely  to  occur  in  the  cannula.  This 
seemed  to  put  a  quietus  on  transfusion  for  more  than 
twenty  years. 

Transfusion  in  America  was  largely  stimulated  by  the 
work  of  Crile,  who  began  experiments  in  1898,  and  by 
the  work  of  Carrel,  who  so  vastly  improved  the  technique 
of  arterial  suture  in  1902.  According  to  Crile,  Queirolo 
was  the  first  to  adopt  an  anastomosis  tube  in  blood-vessel 
surgery  as  is  employed  at  the  present  time.  The  method 


100  SUKGERY    OP    THE    BLOOD-VESSELS. 

of  Crile  consists  in  using  a  canimla  which  varies  from 
the  smallest  size  of  one  and  a  half  millimeters  to  three 
millimeters  inside  diameter.     The  size  that  seems  best 
suited  for  the  caliber  of   the  artery  is   selected.     The 
artery  is  dissected  free,  usually  taking  the  radial  ar- 
tery, the  lower  end  is  tied  and  a  small  ('rile  clamp,  or 
serrefine,  is  placed  on  the  artery  at  the  upper  extremity 
of  the  wound.     The  vein  in  the   forearm  is  next  dis- 
sected, ligating  it  at  the  distal  end  and  clamping  it  with 
a  Crile  clamp,  or  serrefine,  at  the  upper  angle  of  the 
wound.     Care  should  be  taken  to   select  a  large  vein, 
which  is  usually  found  without  difficulty  about  the  elbow. 
These   dissections   can   be   done   with   local   anesthesia, 
either  one-fifth  of  one  percent   solution   of  cocaine   or 
one-half  of  one  percent  of  novocaine  to  which  a  small 
amount  of  adrenalin  has  been  added.     Tablets  of  novo- 
caine and  suprarenal  extract  are  on  the  market.     The 
region  of  the  artery  is  infiltrated.     The  dissection  should 
be  made  under  a  good  light.     Each  bleeding  point  is 
caught  with  small  mosquito  hemostats  so  the  field  can  be 
kept  clear.     Small  branches  of  the  radial  artery  must  be 
clamped  and  tied  with  fine  silk.     The  vein  is  freed  in  a 
similar  manner.     The  artery  is  then  cut  across  near  the 
ligature  and  its  adventitia  removed,  as  described  in  the 
technique  of  suturing  blood-vessels,  by  pulling  it  over 
the  end  of  the  vessel  with  the  thumb  and  finger  and  cut- 
ting it  off.     Or  it  may  be  grasped  with  small  dissecting 
forceps  and  cut  away.     The  end  of  the  artery  is  anointed 
with  sterile  vaseline.     The  vein  is  treated  in  a  similar 
manner.     The  handle  of  the  Crile  cannula  is  clamped  with 
a  pair  of  hemostats  and  the  vein  threaded  through  the 
cannula,  entering  at  its  base  at  the  handle.     The  vein  is 
then  caught  by  three  mosquito  hemostats  and  cuffed  back 
over  the  cannula  by  traction  on  all  three  mosquito  hemo- 


TRANSFUSION    OF    BLOOD. 


101 


Fig.  46. —  (A)  Crile  cannula.  (B)  Thread  in  the  vein  to  draw  it  through  cannula. 
(C)  The  vein  is  caught  by  three  mosquito  hemostats  and  cuffed  back  over  the 
cannula,  and  at  (D)  is  tied  over  the  ridge  next  to  the  handle.  It  is  lightly 
smeared  with  oil  or  vaseline  and  the  artery  slipped  over  the  cuffed  vein  and 
fastened  with  a  suture  on  the  ridge  farthest  from  the  handle.  (E)  The  opera- 
tion completed. 


102  SURGERY    OF    THE    BLOOD-VESSELS. 

stats  at  the  same  time.  It  is  tied  firmly  with  fine  linen  in 
the  groove  next  to  the  handle  and  is  covered  with  sterile 
vaseline,  care  being  taken  not  to  get  any  vaseline  in  the 
open  end.  A  pair  of  closed  mosquito  hemostats  is 
anointed  with  vaseline  and  inserted  into  the  end  of  the 
artery  very  gently.  It  is  opened  gradually  so  as  to  dilate 
the  artery.  Three  mosquito  hemostats  then  grasp  the 
artery  at  equally  distant  points  and  pull  it  over  the  cuffed 
vein  on  the  cannula.  It  is  tied  in  position  on  the  groove 
farthest  from  the  handle  (Fig.  46).  In  this  way  noth- 
ing but  endothelium  is  exposed  to  the  blood  current. 
Often  the  artery  contracts  very  greatly  and  may  appear 
to  be  too  small,  but  after  dilatation  it  can  usually  be 
slipped  over  the  cuffed  vein.  Sometimes,  three  guy  su- 
tures may  be  used  instead  of  the  hemostats.  Occasion- 
ally the  vein  or  artery  is  kinked,  but  by  making  a  little 
tension  on  it  in  the  axis  of  the  vessel  first  toward  the 
artery  and  then  toward  the  vein  the  kink  may  be  straight- 
ened out.  The  clamp  on  the  vein  should  be  first  removed 
and  then  the  clamp  on  the  artery  is  gradually  loosened. 
Another  very  popular  method  of  transfusion  of  blood 
and  one  that  is  simple  in  application  is  by  means  of  a 
tube.  This  was  first  brought  prominently  to  attention  as 
a  practical  measure  by  Brewer  and  Ligget.  The  older 
methods  of  tubes  and  syringes,  such  as  the  Aveling  trans- 
fusion apparatus,  were  found  impracticable  because  of 
the  rapid  clotting  of  blood.  It  has  been  known,  how- 
ever, that  blood  clots  less  rapidly  on  a  smooth  surface 
and  in  the  presence  of  oil,  or  paraffin.  Brewer's  tubes 
are  made  of  thin  glass  and  vary  in  size.  One  end  is  usu- 
ally larger  than  the  other  for  insertion  in  the  vein. 
They  are  slightly  flared  at  each  end  to  prevent  the  liga- 
tures slipping  off  (Fig.  47).  When  ready  for  use  the 
vein  and  artery  are  prepared,  as  already  indicated, 


TRANSFUSION    OF    BLOOD.  KK> 

though  it  is  not  necessary  to  dissect  out  quite  as  much 
artery  or  vein  as  would  be  the  case  if  direct  suture  or  a 
Crile  cannula  were  used.  The  tubes  are  sterilized  by 
boiling  and  just  before  being  used  are  dipped  in  melted 
paraffin,  the  excess  of  the  paraffin  being  shaken  out  of  the 
lumen  so  as  to  prevent  occlusion  of  the  lumen.  Cumol 
or  liquid  albolene  or  some  paraffin  oil  may  be  used  in- 
stead of  paraffin.  The  artery  is  dilated  by  the  insertion 
of  a  closed  mosquito  forceps  covered  with  vaseline  and 


1 


t 


Fig.   47. — Brewer's    glass    tubes    for    transfusion.      They    are    of    different    shapes    and 
sizes,   made   from   thin   glass,    and   have   flared   ends   to   hold   ligatures. 

is  so  stretched  that  the  small  end  of  the  tube  can  be  in- 
troduced. The  artery  is  drawn  over  this  end  by  three 
mosquito  hemostats.  A  ligature  fastens  the  tube  in  the 
artery.  The  vein  is  also  caught  with  three  mosquito 
hemostats  at  equally  distant  points  and  a  small  spurt 
of  blood  is  allowed  to  come  through  the  cannula  to  expel 
the  air.  The  large  end  of  the  tube  is  then  inserted  into 
the  vein  and  fastened  with  a  ligature.  The  clamp  is  re- 
moved first  from  the  vein  and  then  from  the  artery. 
Numerous  modifications  of  the  Brewer  tube  have  been 
made. 

Fauntleroy,  of  the  United  States  Navy,  has  suggested 


104  SURGERY    OF    THE    BLOOD-VESSELS. 

a  S-sliaped  tube  and  makes  the  anastomosis  from  vein 
to  vein.  Bernheim,  of  Baltimore,  constructs  the  tube  of 
metal  and  in  two  pieces  which  are  accurately  fitted,  and 
after  their  insertion  into  the  vein  and  artery,  respec- 
tively, the  two  halves  can  be  joined  and  the  blood  cur- 
rent turned  on  (Fig.  48).  He  claims  that  in  case  of  clot- 
ting, the  clots  can  be  removed  without  the  necessity  of 
taking  the  tube  from  the  artery  and  the  vein,  as  would 
be  necessary  if  clotting  occurred  in  the  Brewer  tube. 

Modifications  of  the  Crile  cannula,  which  itself  has 
been  modeled  on  the  tube  of  Payr,  are  numerous.  Bern- 
heim has  modified  the  Crile  cannula  by  prolonging  the 
handle  and  placing  three  small  hooks  on  the  base  of  the 
cannula  so  the  vein  after  insertion  and  being  cuffed  back 
can  be  fastened  on  to  these  hooks  instead  of  being  tied. 

Hepburn  has  also  modified  the  Crile  cannula  by  adding 
a  wide  flange  at  its  base  which  is  perforated  with  four 
holes.  These  perforated  holes  aid  in  cuffing  back  the 
vein  and  in  drawing  the  artery  over  the  vein.  Here  su- 
tures are  used  instead  of  mosquito  hemostats  for  cuffing 
back  the  vein. 

Robert  C.  Bryan  and  F.  R.  Ruff,  of  Richmond,  de- 
vised an  ingenious  modification  of  the  Crile  cannula, 
which  is  made  as  a  hinged  tube.  The  vein  is  placed  in 
the  open  cannula  and  the  cannula  is  then  closed.  This 
avoids  the  necessity  of  threading  the  vein  through  the 
cannula,  which  is  sometimes  difficult.  Bryan's  modi- 
fication includes  a  longer  handle  and  a  cannula  of  larger 
caliber  than  the  regular  Crile  cannula  (Fig.  49). 

The  cannula  of  Elsberg  is  built  on  the  principle  of  the 
monkey-wrench.  It  can  be  enlarged  or  narrowed  by 
turning  a  nut  at  the  end  of  the  handle  (Fig.  50).  The 
cannula  is  first  opened  and  slipped  under  and  around 
the  artery  and  is  then  closed  so  as  to  compress  the 


TRANSFUSION    OF   BLOOD. 


105 


106 


SURGERY    OF    THE    BLOOD-VESSELS. 


artery.  The  artery  is  tied,  cut  a  third  of  an  inch  from 
the  cannula,  cuffed  back  over  the  cannula,  and  fastened 
on  little  hooks.  The  vein  is  exposed  and  the  artery 


Fig.   49. — Modification   of  Crile  cannula  by  Robert  C.   Bryan,   which  facilitates  placing 

the  vein   in  position. 


on  the  cannula  is  slipped  through  a  small  slit  in  the  vein. 
The  cannula  is  then  gradually  opened  until  blood  flows 
freely  and  until  the  wound  in  the  vein  is  tense  and  does 
not  leak. 

Ottenberg  employs  a  silver  ring  with  two  grooves  on 


Fig.   50. — Cannula    of    Elsberg   which   works    on   the   principle    of    the    monkey-wrench. 

its  surface.  The  technique  of  using  it  is  similar  to  that 
of  Crile,  except  that  he  has  a  special  instrument  to  hold 
the  ring  and  fastens  the  vessel  to  the  ring  with  silver 
wire. 

Soresi   employs    double   cylinders,   which   open   on    a 


TRANSFUSION    OF    BLOOD.  107 

pivot.  These  cylinders  slide  on  a  small  bar.  The  vessel 
is  placed  in  the  open  cylinder,  which  is  then  closed,  and 
the  vessel  is  cuffed  back  over  each  cylinder  and  caught  on 
hooks,  which  hold  it  in  this  position.  The  cylinders  are 
adjusted  on  the  sliding  bar  until  the  intima  of  each  ves- 
sel is  in  contact,  then  the  blood  stream  is  turned  on.  1  Ie 
advocates  vein-to-vein  transfusion. 

Janeway  uses  for  transfusion  an  instrument  consist- 
ing of  two  parts,  which  may  be  joined  together  and  fas- 
tened securely,  each  half  resembling  a  thumb  forceps, 
each  blade  of  which  terminates  in  half  a  cylinder.  The 
vessels  are  placed  within  the  cylinders  which  are  then  ad- 
justed by  the  thumb  screw  on  the  blade  of  the  forceps. 
Each  vessel  is  cuffed  back.  The  two  halves  are  joined 
together  by  means  of  a  shoulder  from  one-half  of  the 
instrument  which  is  called  the  male  half  and  fits  into  a 
socket  in  the  other  half  of  the  instrument,  the  female 
half.  If  desired  and  one  vessel  is  much  larger  than  the 
other  the  smaller  vessel  can  by  this  instrument  be  in- 
vaginated  into  the  larger  vessel  and  sutured  in  this  posi- 
tion. 

Frank  and  Baehr  advise  that  preserved  blood-vessels 
be  used  as  the  links  between  the  artery  and  vein  in  trans- 
fusion. The  end  of  each  link  is  fitted  with  a  Crile  can- 
nula  and  the  link  cuffed  back.  In  transfusion  one  end 
of  the  link  is  inserted  into  the  vein  and  the  other  into  the 
artery. 

Hartwell  suggests  stripping  the  adventitia  from  the 
end  of  the  artery  and  then  rolling  some  of  it  back  so  as 
to  form  a  ridge  about  one  and  a  half  inches  from  the 
cut  end  of  the  artery,  which  is  well  anointed  with  vase- 
line and  inserted  into  the  vein  by  means  of  three  sutures 
of  fine  silk  passed  at  equally  distant  points  through  the 
cut  end  of  the  vein.  The  vaselined  end  of  the  artery  is 


108  SUEGEEY    OF    THE    BLOOD-VESSELS. 

fixed  in  position  by  passing  one  of  the  sutures  through 
the  ridge  of  adventitia  on  the  artery.  The  surplus  cir- 
cumference of  the  vein  is  taken  up  by  a  small  clamp  or 
by  the  other  two  sutures. 

Dorrence  and  Ginsburg  advocate  vein-to-vein  transfu- 
sion. The  advantages  they  claim  are  that  it  is  easier  and 
that  there  is  no  danger  of  dilatation  of  the  heart.  Two 
superficial  veins  are  connected  on  the  forearm  usually  by 
means  of  a  cannula  such  as  the  tube  of  Brewer,  or  by 
the  cannula  of  Crile.  The  distal  end  of  the  vein  in  the 


Fig.  51. — Curtis  and  David's  apparatus  for  transfusion. 

donor  is  connected  with  the  proximal  end  of  the  vein  in 
the  recipient.  A  light  tourniquet  on  the  arm  of  the 
donor  above  the  point  of  anastomosis  hastens  the  flow. 

Indirect  transfusion  may  be  done  by  drawing  the  blood 
into  a  large  syringe  that  is  coated  with  albolene  or  liquid 
vaseline,  and  then  injecting  it  immediately  into  the  vein 
of  the  recipient. 

Curtis  and  David  used  a  Y-shaped  cannula  for  vein- 
to-vein  transfusion  (Fig.  51).  The  cannula  is  coated 
with  sterile  vaseline,  one  arm  is  inserted  into  the  proxi- 
mal end  of  the  recipient's  vein  and  the  other  in  the  distal 


TRANSFUSION    OF    BLOOD.  109 

end  of  the  donor's  vein.  A  glass  syringe,  the  interior  of 
which  has  been  coated  with  vaseline,  is  now  fitted  to  the 
neck  of  the  cannula.  The  vein  of  the  recipient  is 
clamped  and  the  vein  of  the  donor  is  loosened  while  the 
syringe  draws  up  blood,  then  the  vein  of  the  donor  is 
clamped  and  the  clamp  on  the  vein  of  the  recipient  is  re- 
leased while  the  syringe  forces  the  blood  into  the  vein 
of  the  recipient.  This  procedure  is  repeated  until  the 
proper  amount  of  blood  has  been  transferred. 

Tuffier,  of  Paris,1  describes  a  simplified  technique  for 
transfusion  in  which  he  uses  three  silver  tubes  coated 
with  paraffin.  He  connects  the  internal  saphenous  vein 
of  the  patient  to  the  radial  artery  of  the  donor.  Lateral 
wounds  are  made  in  the  vessels  and  one  end  of  the  tube 
is  inserted  in  the  artery  and  the  other  end  introduced 
into  the  vein.  The  operation  is  on  the  principle  of  Brew- 
er's tube. 

Other  measures,  such  as  bleeding  the  donor  into  salt 
solution  and  injecting  the  mixture  intravenously,  have 
been  suggested. 

Kimpton  and  Brown  2  devised  a  large  glass  tube  which 
is  coated  with  paraffin  on  the  inside.  The  upper  end  is 
closed  with  a  cork  stopper.  A  side  tube  runs  out  from 
the  main  tube  a  short  distance  below  the  cork.  The 
lower  end  of  the  tube  is  drawn  out  into  a  small  cannula 
which  is  bent  so  as  to  form  a  trap  when  the  large  tube 
is  placed  horizontal.  From  the  last  bend  the  cannula 
should  not  be  more  than  two  or  three  inches  long  and 
should  taper  gradually  into  a  bevelled  and  smooth  point 
about  two  to  three  millimeters  in  diameter  (Figs.  52  and 
53).  When  ready  for  use  a  small  piece  of  paraffin  is 
placed  in  the  cylinder,  the  cork  inserted,  and  the  whole 


1  Presse   Medicale,   July   31,    1912. 

2  Journal  A.  M.   A.,  July,   1913,  page   117. 


110 


SURGERY    OF    THE    BLOOD-VESSELS. 


Pig.    52. — Kimpton    and    Brown's    apparatus    for    transfusion. 


Fig.   53. — Kimpton    and    Brown's    cannula    in    horizontal    position,    showing    the    trap 
which   prevents   the   entrance   of    air   in   the   cannula. 


TRANSFUSION    OF    BLOOD.  Ill 

apparatus  wrapped  in  a  towel  and  sterilized  in  the  auto 
clave  with  the  dressings.  After  removing  the  tube  it  is 
heated  over  a  Bunsen  burner  and  the  paraffin  carefully 
coated  over  the  interior  of  the  tube,  the  excess  running 
out  of  the  cannula.  The  cannula  should  then  be  cooled 
as  quickly  as  possible  without  breaking.  Sterile  absorb 
ent  cotton  is  placed  in  the  side  tube.  AVhen  in  use  the 
cannula  is  inserted  into  a  wound  in  the  artery  and  the 
tube  held  vertical!}"  until  it  is  filled  with  blood.  The  tube 
is  then  brought  to  a  horizontal  position  and  the  cannula 
inserted  into  the  vein.  The  tube  is  again  brought  to  a 
vertical  position  and  the  blood  allowed  to  run  into  the 
vein.  A  bulb,  as  from  a  Paquelin  cautery,  is  attached  to 
the  side  tube  and  with  very  little  air  pressure  the  ap- 
paratus empties  itself  through  the  cannula.  The  can- 
nula may  hold  250  cubic  centimeters  and  two  cannulas 
may  be  used  so  one  can  be  filled  while  the  other  is  being 
emptied.  The  vein  of  the  donor,  instead  of  the  artery, 
may  be  used. 

Edward  Lindeman,3  of  New  York,  describes  a  new 
method  of  indirect  transfusion.  A  small  needle,  the  size 
of  a  small  aspirating  needle,  surrounded  by  two  cannulas 
is  used  to  enter  the  vein  of  the  donor  and  another  simi- 
lar set  for  the  recipient.  The  cannulas  may  be  lined 
with  a  film  of  albolene.  A  series  of  Record  syringes  that 
fit  the  outer  cannula  and  of  a  twenty  cubic  centimeter 
capacity  is  sterilized.  When  the  vein  of  the  recipient 
is  entered  and  blood  appears  in  the  cannula  a  syringe 
filled  with  warm,  normal  salt  solution  is  immediately  at- 
tached to  the  cannula  and  a  very  slow  flow  of  salt  solu- 
tion is  established  to  prevent  clotting  in  the  cannula. 
The  veins  of  both  donor  and  recipient  are  treated  simi- 
larly. An  empty  syringe  is  then  fitted  to  the  cannula  in 

3  American    Journal    of    Diseases    of    Children,    July,    1913. 


112 


SUKGEEY    OF    THE    BLOOD-VESSELS. 


the  donor  by  an  assistant,  filled  with  blood  and  passed 
quickly  to  the  operator,  who  at  once  injects  the  blood  into 
the  cannula  of  the  recipient.  A  little  normal  salt  solu- 
tion is  injected  through  the  cannula  of  the  recipient  after- 
each  syringe  full  of  blood  to  prevent  clotting  in  the  can- 


Fig.   54. — Landon's    cannula    with   forceps    for    applying    it. 

nula.  Each  syringe  should  be  thoroughly  washed  out 
with  normal  salt  solution  before  being  used  again.  No 
skin  incision  is  necessary.  Usually  the  median  basilic  is 
the  vein  punctured,  with  a  light  tourniquet  on  the  donor. 
In  infants  the  external  jugular  is  better. 

L.  H.  Landon,4  of  Philadelphia,  describes  a  new  self- 


rig.  55. — Method  of  using  Landon's  cannula. 


retaining  tube  for  transfusion  of  blood  (Figs.  54  and 
55).  This  tube  is  a  short  cannula  of  metal  made  in  three 
different  sizes.  One  end  of  the  tube  is  smooth  and  the 
other  has  five  sharp  points  which  are  slightly  everted. 
Two  perforations  in  the  side  of  the  cannula  enable  it  to 

4  Journal  A.   M.   A.,   August   16,    1913,   page  490. 


TRANSFUSION    OF    BLOOD.  113 

be  held  by  special  forceps.  Either  the  artery  or  the  vein 
is  threaded  through  the  cannula,  and  cuffed  back;  then 
the  other  vessel  is  drawn  over.  Both  are  fastened  to  the 
hooks. 

H.  A.  Fraund,5  of  Detroit,  describes  a  method  of  trans- 
fusing fresh  blood  by  means  of  a  well-fitting  aspirating 
syringe  holding  twenty  cubic  centimeters,  a  two-way  stop 
cock  irrigator  with  a  glass  cylinder  attached,  and  two 
tubes  with  needles  leading  from  each  tube.  The  glass 
cylinder  has  a  small  stop  cock  and  the  whole  apparatus 
is  mounted  on  an  inclined  wooden  base.  Normal  salt 
solution  is  poured  into  the  glass  cylinder  and  taken  into 
the  syringe  and  both  needles  are  then  held  so  that  the 
normal  salt  solution  will  go  through  them  and  remove 
the  air.  Blood  is  then  drawn  through  one  of  the  needles 
inserted  into  a  vein  and  thoroughly  mixed  with  the  salt 
solution.  It  is  then  introduced  into  the  recipient. 

Satterle  and  Hooker6  describe  an  indirect  method  of 
transfusion  of  blood  in  which  the  blood  is  drawn  into  a 
paraffin  lined  receptacle  and  injected  into  the  vein  of  the 
recipient. 

B.  F.  McGrath,  of  the  Mayo  Clinic,  has  devised  three 
different  methods  for  transfusion  in  order  to  meet  the 
various  conditions  as  to  size  of  artery,  measurement  of 
blood,  etc.  When  exact  estimation  of  amount  of  blood 
is  required,  he  recommends  a  modification  of  the  old 
Aveling  operation.  A  rubber  bulb  of  about  thirty  cubic 
centimeter  capacity  and  having  two  small  tips  is  filled 
with  salt  solution.  The  tips  are  fastened  into  the  veins 
of  the  donor  and  recipient,  respectively,  the  vein  of  the 
donor  is  clamped  with  a  serrefine,  and  the  bulb  squeezed, 
forcing  the  salt  solution  into  the  vein  of  the  recipient. 

5  Michigan    State    Medical    Society    Journal,    September,    1913. 

6  Archives  of  Internal   Medicine,   January,    1914. 


114 


SURGEHY    OF    THE    BLOOD-VESSELS. 


The  serrefine  is  tlien  transferred  to  the  vein  of  tlie  re- 
cipient, and  the  bull),  released,  draws  in  blood  from  the 
donor.  The  serrefine  is  again  transferred  to  the  vein 
of  the  donor  while  the  bulb  is  compressed.  In  this  man- 
ner thirty  cubic  centimeters  of  blood  are  forced  into  the 
recipient  with  each  emptying-  of  the  bulb.  There  is  some 
danger  of  forcing  in  clots  by  this  method.  McGrath7 


Fig.    56. — Transfusion   forceps   of   McGrath. 

has  also  a  transfusion  forceps  which  can  be  separated 
and  locked  like  obstetrical  forceps.  At  the  end  of  each 
half  is  a  short  cannula  through  which  the  blood-vessel  is 
threaded,  cuffed  back,  and  fastened  on  small  hooks  (Fig. 
56).  The  forceps  are  then  put  together,  gently  locked 
and  the  blood  turned  on.  McGrath  8  advises  transfusion 


7  Journal  A.    M.    A.,   January    3,    1914. 

8  Journal  A.   M.  A.,   April  25,    1914. 


TRANSFUSION    OF    BLOOD.  115 

by  suture  when  the  vessels  are  small  and  has  devised  a 
tripod  which  fits  over  the  artery,  the  three  legs  being 
points  of  attachment  for  the  three  guy  sutures. 

A.  Crotti 9  describes  his  method  of  using  indirect  trans- 
fusion of  blood  by  means  of  a  syringe  with  a  blunt  needle 
in  which  the  blood  is  aspirated  into  the  syringe  and 
injected  into  the  recipient.  The  procedure  can  be  re- 
peated if  the  syringe  is  washed  out  carefully  with  normal 
salt  solution  each  time  after  the  injection.  This  is  simi- 
lar to  the  method  of  Lindeman. 

~W.  L.  Moss,10  of  Johns  Hopkins,  describes  a  method 
of  indirect  transfusion  with  defibrinated  blood.  The 
blood  is  withdrawn  from  the  donor's  vein  into  small  glass 
flasks  by  means  of  an  aspirating  needle  and  a  rubber  tube 
lined  with  a  thin  coating  of  paraffin.  The  blood  is  defi- 
brinated by  being  shaken  in  the  flask  with  a  half  ounce  of 
glass  beads.  It  is  then  filtered  through  sterile  gauze  into 
an  infusion  bottle  containing  300  cubic  centimeters  of 
normal  salt  solution  and  injected  into  a  vein  of  the  recipi- 
ent. The  chief  objection  to  the  use  of  defibrinated  blood 
in  transfusion  was  pointed  out  by  A.  Koehler,  von  Berg- 
mann  and  others  (page  99)  and  consists  in  the  fact  that 
there  is  an  excess  of  fibrin  ferment  which  may  cause  clot- 
ting within  the  vessels. 


9  Surgery,   Gynecology   &   Obstetrics,   February,    1914. 

10  American  Journal  of  the  Medical    Sciences,    May,   1914. 


CHAPTER  VII. 

TRANSFUSION  OF  BLOOD. 

(Continued.) 

Transfusion  is  divided  into  two  types,  the  direct  and 
the  indirect.  In  the  former,  blood  flows  in  a  continuous 
stream  from  the  donor  to  the  recipient,  while  in  the  in- 
direct method  the  blood  is  drawn  from  the  donor  and  in- 
jected into  the  veins  of  the  recipient.  Sometimes  the 
blood  is  diluted  with  salt  solution  or  defibrinated  before 
being  introduced  into  the  recipient,  and  frequently  it  is 
injected  quickly  before  it  can  clot. 

In  considering  the  various  methods  of  transfusion,  two 
things  should  be  borne  in  mind,  efficiency  and  simplicity. 
The  objection  to  any  special  apparatus  is,  of  course,  ob- 
vious. Usually,  this  apparatus  consists  of  cannulas  that 
are  required  to  fit  the  various  calibers  of  the  artery  or 
vein.  In  cannulas  that  permit  contact  of  blood  with 
their  walls,  such  as  the  Brewer  tube,  there  is  the  possi- 
bility of  clotting  to  be  considered.  If  these  instruments 
work  satisfactorily,  nothing  more  can  be  desired,  but 
if  the  proper  size  is  not  at  hand,  if  the  device  is  out  of 
order,  or  if  a  clot  forms  in  the  cannula,  it  may  be  impos- 
sible to  do  the  transfusion,  which  is  always  an  operation 
of  great  necessity.  The  suture  method  avoids  these  ob- 
jections. 

The  vein  in  the  recipient  should  be  chosen  near  some 
branch.  The  branch  is  dissected  out,  divided  and 
clamped  with  mosquito  forceps.  The  main  vein  is  then 
clamped  at  the  proximal  end  of  the  wound  with  a  serre- 

116 


TRANSFUSION    OF    BLOOD.  117 

fine,  ligated  at  the  distal  end  and  divided  and  sutured  to 
the  artery,  as  described  under  the  technique  of  arterial 
suturing  (pp.  50-67).  The  arterial  suture  staff  makes  it 
as  easy  to  suture  a  small  artery  to  a  large  vein,  if  the  dis- 
parity is  not  too  great,  as  to  suture  vessels  of  equal  caliber 
(Fig.  57).  After  the  suturing  is  completed  the  clamp  on 
the  vein  is  removed  first  and  the  clamp  on  the  artery  is 
gradually  loosened.  If  there  is  no  spurting  point,  but 
merely  a  slight  oozing,  the  guy  sutures  to  the  staff  can  be 
cut  and  the  instrument  removed.  If  for  any  reason  clot- 
ting occurs  or  an  excess  of  vaseline  blocks  the  lumen,  the 
finger  can  be  placed  on  the  vein  of  the  recipient  just  above 
the  venous  branch,  and  the  mosquito  forceps  released, 
while  the  thumb  and  forefinger  of  the  other  hand  gently 
manipulate  the  sutured  area.  The  thrombus  is  blown 
out  through  the  venous  branch.  Sometimes  a  valve  ex- 
ists in  the  branch  and  in  this  case  it  can  be  overcome  by 
inserting  a  closed  pair  of  mosquito  forceps,  which  have 
been  anointed  in  vaseline,  and  gently  dilating  the  valve. 
Not  infrequently  in  transfusion  the  artery  contracts  to 
such  a  degree  as  almost  to  stop  the  flow  of  blood.  If  the 
artery  is  kept  covered  with  gauze  wrung  out  of  warm 
salt  solution,  this  is  not  so  likely  to  occur.  Sometimes, 
however,  even  in  spite  of  this,  contraction  of  the  artery 
is  marked.  If  it  is  too  great,  a  smooth  silver  probe,  such 
as  a  lachrymal  probe,  is  thoroughly  anointed  with  vase- 
line, introduced  through  the  venous  branch,  and  carried 
well  up  into  the  radial  artery.  This  procedure  will  at 
once  be  followed  by  a  full  flow  of  blood,  but  it  cannot  be 
done  where  a  cannula  is  used,  only  when  the  union  is 
made  by  sutures.  Usually  after  four  or  five  minutes  a 
clot  will  reform  on  account  of  the  injury  by  the  probe. 
The  probe  can  then  be  reinserted.  A  strong  flow  of  blood 
for  fifteen  minutes  is  ordinarily  sufficient,  and  it  is  better 


118 


SURGERY    OF    THE    BLOOD-VESSELS. 


Pig.  57. — Showing  suturing  applied  to  transfusion  of  blood.  On  the  right  is  a  vein 
which  is  somewhat  larger  than  the  artery.  The  vein  has  a  branch  through 
which  a  smooth  probe  covered  with  vaseline  can  be  inserted  and  pushed  up 
into  the  artery  if  an  obstruction  occurs,  or  if  the  artery  contracts  too  much. 
By  pressing  on  the  main  trunk  of  the  vein,  clots  may  be  blown  out  through 
the  branch. 


TRANSFUSION    OF    BLOOD.  11!) 

to  use  the  probe  several  times  in  this  manner  than  to  <lo 
the  whole  operation  over  again.  If  for  any  reason  the 
suture  line  is  unsatisfactory,  it  can  be  cut  out  dose  1o  tin- 
sutures,  so  sacrificing  only  a  small  portion  of  the  artery 
and  vein;  whereas  when  cannulas  are  employed,  so  much 
of  the  artery  or  vein  has  to  be  cut  away  with  the  cannula 
that  often  not  enough  of  these  vessels  is  left  with  which 
to  do  the  operation  again. 

The  dangers  of  transfusion  that  are  dependent  di- 
rectly upon  the  operation  are  clotting,  formation  of  a 
thrombus  or  embolus,  the  entrance  of  air,  too  great  rapid 
ity  of  flow,  and  infection  in  the  wound.  The  remedy  for 
most  of  these  conditions  is  obvious.  The  danger  from 
thrombus  formation  has  been  greatly  exaggerated,  unless 
large  tubes  are  used,  or  there  is  great  carelessness  at  the 
time  of  the  operation.  If  large  tubes  are  permitted  to 
contain  clotted  blood  which  is  loosened,  trouble  may  re- 
sult, but  the  minute  thrombus  that  would  ordinarily  re- 
sult from  the  line  of  suturing  or  from  a  small  cannula, 
such  as  the  Crile  cannula,  would  hardly  injure  the  patient 
if  the  clot  is  not  septic.  It  has  been  proven  experi- 
mentally that  it  is  very  much  more  difficult  to  create  an 
infarct  in  the  lungs  than  is  usually  supposed.  In  ani- 
mals, sterile  mustard  seed  may  be  introduced  into  the 
veins  without  the  formation  of  infarcts  in  the  lungs  un- 
less the  bronchial  artery  supplying  the  lobe  in  which  the 
seed  lodges  is  ligated.  However,  it  is  just  as  well  not  to 
have  thrombi  introduced  into  the  recipient  and  by  careful 
technique  and  the  selection  of  a  vein  with  a  branch  near 
the  point  of  anastomosis,  as  has  been  suggested,  their  in- 
troduction should  be  obviated. 

The  danger  from  entrance  of  air  has  also  been  greatly 
exaggerated,  as  a  small  amount  of  air  is  rapidly  dis- 
solved in  the  blood  stream.  Large  amounts  introduced 


120  SURGERY    OF    THE    BLOOD-VESSELS. 

in  the  big  veins  of  the  neck,  axilla,  or  groin  are,  of  course, 
dangerous,  but  the  small  quantity  that  would  get  in  dur- 
ing a  direct  transfusion  as  ordinarily  performed  would 
probably  not  be  of  serious  consequence.  In  the  use  of  a 
syringe,  however,  as  recommended  by  some  in  the  vein- 
to-vein  transfusion,  or  in  the  rubber  bulb  of  the  Aveling 
apparatus,  it  is  quite  possible  to  introduce  what  would  be 
a  fatal  amount  of  air. 

Sepsis  is  guarded  against  by  proper  aseptic  tech- 
nique. The  overcrowding  of  the  heart  by  too  much  blood 
should  be  watched  for.  If  the  blood  is  flowing  too  rapidly 
the  artery  may  be  compressed  between  the  finger  and 
thumb  so  as  to  diminish  the  flow  or  check  it  entirely.  The 
heart  should  be  percussed  and  if  there  is  any  suspicion  of 
overcrowding  the  heart  or  the  slightest  sign  of  enlarge- 
ment, transfusion  should  be  stopped  temporarily  or 
permanently.  If  the  heart  dilates,  the  patient  should  be 
placed  upright,  or  in  the  reversed  Trendelenburg  posi- 
tion, and  pressure  made  over  the  heart. 

The  proper  amount  of  blood  to  be  transfused  can  be  es- 
timated by  the  appearance  of  the  recipient,  particularly 
by  the  color  of  the  skin,  by  the  character  and  rate  of  the 
pulse  and  by  the  blood  pressure,  which  may  be  taken  at 
intervals.  Usually  too  little  blood  is  introduced,  but  if  a 
patient  has  been  ill  for  a  long  time  it  is  easy  to  transfuse 
too  much.  When  the  hemorrhage  has  been  acute  and  the 
patient's  organs  have  not  had  time  to  weaken  or  de- 
generate, as  occurs  after  a  long  sickness  or  many  hemor- 
rhages, the  blood  can  be  introduced  much  more  freely 
than  in  an  individual  who  has  been  anemic  for  a  long 
time,  and  whose  heart  and  other  organs  has  been  suffer- 
ing from  the  malnutrition.  Here  the  strain  of  turning 
on  suddenly  too  much  blood  might  result  disastrously. 

In  the  indirect  method  either  the  whole  blood  is  trans- 


TRANSFUSION    OF    BLOOD.  121 

ferred  before  it  has  time  to  clot  or  the  blood  is  diluted 
with  salt  solution  and  is  then  injected  into  the  veins  of 
the  patient.  The  artery-to-vein  direct  method,  partic- 
ularly when  the  union  between  the  artery  and  vein  is 
done  so  as  to  approximate  intima  to  intima,  insures  that 
the  rich  oxygenated  arterial  blood  of  the  donor  is  directly 
transferred  unimpaired  to  the  right  side  of  the  heart, 
Certainly,  a  patient  in  need  of  transfusion  with  all  or- 
gans operating  at  a  low  level  of  vitality  needs  nutritious 
arterial  blood,  which  has  already  been  oxygenated,  more 
than  the  venous  blood  that  contains  the  waste  products  of 
the  tissue  from  which  it  comes.  The  indirect  method 
has  not  only  this  disadvantage  but  the  additional  one  that 
there  may  be  fine  changes  when  blood  stands  even  a  few 
minutes  in  a  syringe  that  will  render  the  blood  less  de- 
sirable than  when  it  is  directly  transfused.  The  chief 
objection  to  the  artery  to  vein  method  is  that  it  may  cause 
dilatation  of  the  heart  by  giving  an  overdose.  These 
symptoms  come  on  gradually  and  can  usually  be  prevented 
by  stopping  the  transfusion  when  such  symptoms  first 
appear. 

Problems  Concerning  the  Donor. 

The  selection  of  the  donor  for  transfusion  requires 
some  care.  Usually,  there  is  but  little  trouble  in  secur- 
ing a  donor  if  the  matter  is  put  frankly  before  the  rela- 
tives and  friends  of  the  patient.  It  should  be  empha- 
sized that  the  operation  will  be  practically  painless  and 
without  danger  to  the  donor,  and  that  no  more  blood  will 
be  used  than  is  considered  necessary.  If  an  appeal  of 
this  kind  is  not  heeded,  sometimes  money  must  be  offered 
for  a  suitable  donor.  He  should  be  selected  without 
sentiment  and  with  regard  to  what  would  be  best  for 
the  recipient.  As  a  rule  young  people,  either  male  or 


122  SURGERY    OF    THE    BLOOD-VESSELS. 

female,  are  the  most  acceptable.  Their  arteries  are 
soft  and  they  can  stand  the  loss  of  blood  much  better  than 
the  old.  Each  donor  should  be  carefully  examined,  par- 
ticularly in  regard  to  the  possibility  of  syphilis,  either 
hereditary  or  acquired.  Of  course,  it  would  be  unwise  to 
use  one  who  is  septic  in  any  form  or  who  has  tuberculosis, 
though  the  latter  might  be  acceptable  under  certain  con- 
ditions. 

The  amount  of  blood  drawn  from  the  donor  is  difficult 
to  estimate,  as  the  flow  is  dependent  upon  the  blood  pres- 
sure of  the  donor,  the  size  of  his  artery,  the  resistance  of 
the  recipient,  the  duration  of  the  flow  and  the  size  of  the 
opening  where  the  artery  is  joined  to  the  vein.  Most  of 
these  conditions  vary  continuously.  The  artery  may  con- 
tract from  exposure  to  cold  or  the  blood  pressure  of  the 
donor  may  change  from  psychic  causes,  or  from  the  loss 
of  blood.  The  size  of  the  opening  may  be  altered  by  de- 
posit of  fibrin,  and  the  resistance  of  the  recipient  will  also 
be  a  variable  factor.  For  these  reasons  it  is  best  to  be 
guided  in  the  amount  of  blood  transfused  largely  by 
clinical  symptoms.  If  the  color  of  the  donor  appears 
distinctly  paler  than  normal  and  the  pulse  rapid,  trans- 
fusion should  be  discontinued.  If  the  condition  is 
psychic  and  more  blood  is  needed,  it  may  be  wise  to  stop 
for  a  while  and  then  start  the  flow  again.  As  a  rule, 
however,  it  is  best  to  discontinue  entirely  under  these  con- 
ditions. The  excitement  of  the  surroundings  and  the 
knowledge  that  the  donor  is  proving  of  benefit  to  the 
recipient  usually  tend  to  hold  up  the  blood  pressure.  If 
it  falls  father  rapidly  from  normal  and  reaches  as  low 
as  110  or  115  the  transfusion  should  be  stopped  at  once 
regardless  of  other  symptoms.  The  artery  of  the  donor 
should  be  ligated  well  up  to  the  wound  with  catgut  and 
due  care  should  be  taken  to  see  that  the  wound  in  the 


TRANSFUSION    OF    BLOOD.  11'. i 

donor  is  not  infected  by  any  of  the  tissues  or  juices  from 
the  wound  in  the  recipient.  The  wound  should  be  closed 
with  interrupted  sutures  or  with  a  button  hole  stitch, 
leaving  a  small  catgut  or  silkworm  gut  drain,  as  the 
length  of  the  manipulations  and  the  exposure  of  the 
wound  often  cause  a  mild  infection. 

Concerning  the  Recipient. 

The  chief  danger  to  the  recipient  is  from  an  overdose 
of  blood.  In  transfusion  as  in  every  valuable  therapeu- 
tic measure,  the  dose  should  be  regulated;  if  too  much 
blood  is  given  the  heart  may  be  strained  unduly,  while 
with  too  little  the  required  effect  may  not  be  obtained. 
If  the  flow  is  free,  just  as  soon  as  the  patient's  color  has 
improved  markedly,  his  pulse  has  decreased  in  rate,  and 
his  blood  pressure  increased  twenty  to  thirty  points,  it  is 
best  to  discontinue  the  transfusion  whether  it  has  lasted 
ten  or  forty  minutes.  Twenty  minutes  is  an  average  time, 
though  with  a  young  child  or  a  thin  patient  this  might  be 
too  long.  The  hemoglobin  should  be  increased  by  about 
fifty  or  sixty  percent  of  what  it  was  before  transfusion. 

Cases  of  secondary  anemia  due  to  whatever  cause, 
whether  the  result  of  small  hemorrhages  for  a  long  time 
or  of  sepsis,  sometimes  become  partly  accommodated  to 
the  low  grade  of  anemia.  Byford  l  has  called  attention 
to  this  in  women  who  have  lost  an  excessive  amount  of 
blood  from  the  uterus,  extending  over  a  long  period  of 
time.  Sometimes  the  organs  have  become  accommodated 
to  a  hemoglobin  of  forty  or  fifty  and  the  patient  will  be 
apparently  enjoying  good  health,  but  a  little  extra  hemor- 
rhage or  strain  will  entirely  break  down  the  resistance. 
In  transfusing  such  patients  if  an  effort  is  made  to  double 
the  hemoglobin,  so  much  blood  will  be  administered  that 

i  Surgery,    Gynecology   &   Obstetrics,    September,    1913. 


124  SURGERY    OF    THE    BLOOD-VESSELS. 

the  heart  and  other  organs  cannot  stand  the  strain,  and 
even  if  they  do  the  patient  is  often  uncomfortable  with 
headaches  and  other  symptoms  that  are  only  relieved 
when  the  hemoglobin  falls.  In  acute  hemorrhages  in- 
volving a  large  loss  of  blood  the  hemoglobin  can  be 
brought  practically  to  what  it  was  before  the  hemorrhage 
occurred. 

In  fat  persons  the  veins  are  small  and  it  is  sometimes 
very  difficult  to  secure  a  vein  in  the  forearm  of  proper 
size  for  transfusion.  It  is  useless  to  attempt  transfusion 
except  with  a  vein  that  is  larger  than  the  donor's  artery, 
preferably  considerably  larger.  If  the  veins  about  the 
elbow  are  not  large  enough  the  basilic  vein  of  the  arm  or 
the  saphenous  in  the  leg  may  be  used. 

The  blood  pressure  of  the  recipient  should  be  taken 
occasionally  and  when  clinical  symptoms  and  increased 
blood  pressure,  as  mentioned  above,  indicate  that  enough 
blood  has  been  transfused,  transfusion  should  cease. 
Dilatation  of  the  heart  is  preceded  by  a  full  and  slow 
pulse  with  very  little  strength,  by  precordial  pain,  and 
often  by  dyspnoaa  and  cyanosis.  These  symptoms,  as  a 
rule,  come  on  gradually  and  at  their  first  inception  the 
transfusion  should  be  stopped  and  the  patient  set  up  on 
the  table,  or  placed  in  a  reversed  Trendelenburg  position. 
Massage  over  the  region  of  the  heart  should  be  done  and 
small  doses  of  nitroglycerine  may  be  given.  It  is  best 
to  give  both  the  recipient  and  donor  from  one-sixth  to 
one-fourth  of  a  grain  of  morphine  with  one  120th  of  a 
grain  of  atropine  a  half  hour  before  the  operation.  This 
stimulates  the  heart  and  tends  to  quiet  both  donor  and 
recipient.  If  the  transfusion  is  done  for  such  affections 
as  illuminating  gas  poisoning,  the  recipient  should  be  bled 
as  much  as  he  can  reasonably  stand  before  turning  on 
blood  for  the  transfusion. 


TRANSFUSION    OF    BLOOD.  1  l2f) 

The  question  of  hemolysis,  which  formerly  was  con- 
sidered a  great  objection,  need  not  be  seriously  consid- 
ered if  a  donor  who  is  of  the  same  race  as  the  recipient 
and  who,  better  still,  is  a  blood  relative  is  selected.  It' 
the  transfusion  is  done  for  pathologic  hemorrhage,  or  for 
pernicious  anemia,  hemolysis  may  result,  but  for  second- 
ary anemia  due  to  repeated  hemorrhages  or  acute  anemia 
following  a  large  hemorrhage,  there  is  practically  no 
danger  from  hemolysis  with  the  selection  of  a  proper 
donor.  Hemolysis  in  vitro  is  so  different  from  the  con- 
ditions in  vivo  as  to  make  it  doubtful  if  a  laboratory  test 
of  hemolysis  between  donor  and  recipient  will  be  of  any 
real  advantage.  No  instances  of  serious  hemolysis  have 
been  reported  with  a  donor  selected  as  just  suggested 
except  in  pathologic  hemorrhages,  and  in  one  of  the  most 
noted  cases — that  of  Pepper  and  Nesbit— it  seems  possi- 
ble at  least  that  some  hemolysis  was  present  even  before 
the  transfusion. 

However,  if  it  is  concluded  to  make  a  laboratory  test 
for  hemolysis  the  following  method  by  Morris  Fishbein  - 
for  the  selection  of  a  donor  in  transfusion  of  blood  may 
be  used.  "So  far  as  the  blood  of  the  donors  to  be  tested 
is  concerned,  sufficient  blood  may  be  obtained  from  the 
ear;  but  in  the  case  of  the  patient  it  would  be  better  to 
draw  the  blood  from  the  median  basilic  vein  of  the  arm 
in  the  usual  way  because  more  serum  is  required.  Three 
drops  of  the  blood  are  added  to  ten  cubic  centimeters  of 
a  one  percent  solution  of  sodium  citrate  in  physiologic 
salt  solution.  In  this  manner  approximately  a  two  per- 
cent suspension  of  the  blood  is  prepared,  the  citrate  pre- 
venting coagulation.  The  remaining  blood  is  poured  into 
a  centrifuge  tube  and  allowed  to  clot.  With  a  clean 
needle  the  clot  is  loosened  from  the  side  of  the  tube  and 


2  Journal   A.   M.   A.,    September   7,    1912,   page   793. 


126  SURGERY    OF    THE    BLOOD-VESSELS. 

the  tube  centrifuged  for  a  few  minutes  to  obtain  an  upper 
layer  of  absolutely  clear  serum.  This  completes  the 
preparation  of  material,  with  the  exception  of  the  plate 
which  is  now  to  be  described  and  which  has  been  found 
to  be  very  serviceable.  On  an  ordinary  piece  of  window 
glass,  approximately  two  by  four  inches  in  size,  which 
has  been  washed  absolutely  clean  with  water  and  ether, 
ten  small  circles  are  made  with  melted  paraffin,  assuming 
that  a  choice  is  to  be  made  among  five  donors.  If  the 
melted  paraffin  is  drawn  up  into  a  medicine-dropper,  the 
circles  are  quickly  made  with  the  tip  while  gentle  pres- 
sure is  exerted  on  the  bulb.  Ten  circles  may  be  made 
with  one  medicine-dropper  full  of  melted  paraffin.  In 
this  manner  ten  paraffin  cups  are  made,  each  of  which 
will  hold  at  least  four  drops.  The  circles  are  made  in 
two  rows  of  five  each.  In  each  cup  in  the  first  row  is 
placed  one  drop  of  the  suspension  of  the  patient's  blood, 
and  in  each  cup  in  the  second  row  are  placed  two  drops 
of  the  patient's  serum.  To  Cup  one  in  the  first  row  are 
added  two  drops  of  serum  of  Donor  I,  to  Cup  two,  two 
drops  of  serum  of  Donor  II,  etc.  To  Cup  one  in  the  sec- 
ond row  is  added  one  drop  of  the  blood  of  Donor  I,  and  to 
Cup  two,  one  drop  of  the  blood  of  Donor  II,  etc.  There 
are  therefore  required  in  such  a  set  five  drops  of  pa- 
tient's blood  suspension,  and  ten  drops  of  patient's 
serum,  and  one  drop  of  each  donor's  blood  suspension 
and  two  drops  of  serum.  With  a  narrow  glass  rod  the 
fluids  are  mixed  thoroughly,  the  rod  being  washed  in  ci- 
trate solution  and  wiped  after  each  mixing.  In  prac- 
tically all  instances,  iso-agglutination  when  present  be- 
comes visible  macroscopically  after  half  an  hour  at  room 
temperature;  the  mixture  can  be  inspected  easily  under 
the  microscope  also.  It  is  obvious  that  in  testing  for  iso- 
agglutination  in  larger  groups,  as  in  twenty,  the  greatest 


TRANSFUSION    OF    BLOOD.  ]'2~ 

advantage  is  to  be  derived  from  this  mot  hod.  It  ha* 
seemed  so  simple  and  easy  of  performance  in  comparison 
with  other  methods  that  it  was  thought  best  to  make  a 
brief  report  of  it." 

Operating-  Room  Technique. 

The  arrangement  of  the  operating  room  should  bo  so 
that  the  head  of  the  recipient  points  in  an  opposite  direc- 
tion from  the  head  of  the  donor.  Two  operating  tables 
or  two  stretchers,  for  the  recipient  and  donor,  should  bo 
placed  in  such  a  position  that  the  left  arm  of  the  recipient 
is  in  easy  contact  with  the  left  hand  and  forearm  of  the 
donor.  The  hand  and  forearm  of  the  donor  should  be  in 
contact  with  the  ulna  side  of  the  forearm  of  the  recipient. 
A  small  table  between  the  two  stretchers  serves  for  a 
place  on  which  the  arms  of  the  donor  and  the  recipient 
rest.  There  should  be  a  stool  for  the  operator  and  one 
for  the  assistant  on  the  opposite  sides  of  this  table.  A 
good  light  and  an  abundance  of  patience  are  necessary. 
It  is  well  to  talk  to  the  donor  and  possibly  the  recipient 
during  the  operation  so  as  to  encourage  them  as  much 
as  possible.  Local  anesthesia  should  be  used  for  both 
donor  and  recipient.  One-fifth  of  one  percent  solution 
of  cocaine  can  be  employed,  or,  better  still,  one-half  of 
one  percent  of  novocaine  to  which  a  small  amount  of  a 
suprarenal  extract  has  been  added.  This  latter  anes- 
thetic is  sometimes  safer  than  cocaine  and  with  the  supra- 
renal extract  will  last  as  long  as  cocaine.  Tablets  con- 
taining these  two  substances  are  on  the  market.  The 
radial  artery  is  exposed  through  an  incision  of  about 
three  inches.  Mosquito  forceps  with  which  to  clamp 
each  bleeding  spot  should  be  ready.  The  field  must 
be  as  dry  as  possible.  The  artery  is  handled  gently 
and  the  little  branches  that  come  from  it  are  clamped 


128  SUEGERY    OF    THE    BLOOD-VESSELS. 

with  mosquito  forceps  and  tied  with  fine  black  silk. 
The  radial  artery  is  ligated  with  catgut  at  the  lowest 
end  of  the  incision,  the  blood  stripped  up  with  the  fin- 
ger and  thumb  and  a  serrefine  placed  on  the  artery  at 
the  upper  end  of  the  incision.  The  vein  in  the  recipient 
is  then  exposed.  Grasping  the  skin  over  a  prominent 
vein  near  the  elbow  with  forceps,  lifting  it  from  the  vein 
and  cutting  out  a  small  patch  of  skin,  will  expose  the 
vein  quickly  without  injury  and  without  the  need  of  re- 
tractors. This  oval  exposure  can  be  extended  by  a 
straight  incision  in  any  direction  needed.  The  vein 
should  be  so  selected  that  a  fairly  large  venous  branch 
comes  off  near  the  point  of  proposed  anastomosis.  A 
ligature  is  placed  on  the  vein  at  the  lower  end  of  the 
wound  and  a  serrefine  clamp  at  the  upper  end.  First  the 
artery  and  then  the  vein  are  cut  across  near  the  ligature, 
the  adventitia  is  removed,  and  the  ends  are  anointed 
with  white  vaseline  and  united  as  has  already  been  de- 
scribed after  the  technique  for  suturing  blood-vessels. 

Indications  for  Transfusion. 

The  field  for  transfusion  may  be  roughly  divided  into 
anemia  from  loss  of  normal  blood,  anemia  from  patho- 
logic hemorrhage,  anemia  due  to  the  hemolytic  action 
of  some  toxin,  and  shock.  When  anemia  is  due  to  either 
the  direct  or  indirect  hemolytic  action  of  a  toxin  the  de- 
cision as  to  transfusion  must  depend  upon  whether  the 
source  of  the  hemolysis  can  be  eradicated.  If,  for  in- 
stance, it  is  the  toxin  that  is  responsible  for  leukemia  or 
pernicious  anemia,  where  the  new  blood  is  soon  acted 
upon  by  the  agent  that  has  already  destroyed  the  blood 
of  the  recipient,  transfusion  is  generally  useless  and  is, 
indeed,  hardly  justifiable.  Reports  on  transfusion  for 
pernicious  anemia  and  for  leukemia  are  summed  up  by 


TRANSFUSION    OF    BLOOD.  ll)(J 

Crile  3  with  the  statement  that  it  has  not  been  demon 
strated  that  either  of  these  diseases  is  favorably  modified 
by  transfusion,  even  in  an  early  stage,  and  that  in  an  ad- 
vanced stage  neither  of  them  is  benefited  by  transfusion. 
When  we  consider  the  fact  that  the  reaction  from  a 
hemolytic  agent  may  be  slightly  different  on  the  donor's 
blood  from  that  of  the  recipient,  we  can  readily  under- 
stand that  there  is  a  possibility  of  adding  other  toxic- 
products  formed  by  the  destruction  of  the  donor's  blood 
within  the  vascular  system  of  the  recipient  that  possibly 
might  not  be  produced  when  the  recipient's  blood  is  the 
sole  source  of  the  hemolytic  material.  The  direct  cause 
of  hemo lysis  in  these  two  diseases  is  not  definitely  known, 
and  its  source  cannot  be  eradicated. 

In  malignant  tumors  there  has  apparently  been  some 
slight  benefit  by  transfusion.  In  cancer  no  beneficial  re- 
sult has  been  obtained  in  checking  the  growth,  but  in 
sarcoma  or  carcinoma  where  the  disease  is  not  too  ex- 
tensive, patients  who  are  in  poor  condition  or  who  have 
lost  much  blood,  as  from  uterine  hemorrhages,  may  by 
transfusion  be  made  much  better  surgical  risks.  In 
tuberculosis  there  sometimes  seems  to  be  some  benefit, 
but  in  surgical  tuberculosis  transfusion  should  be  advised 
only  to  improve  an  operable  risk.  In  chronic  suppura- 
tion or  in  sepsis  where  no  distinct  septicemia  or  pyemia 
exists,  transfusion  often  produces  brilliant  results.  In 
shock  and  collapse  it  is  a  most  valuable  remedy.  In 
hemorrhage,  particularly  when  the  blood  is  not  patho- 
logic, transfusion  is  practically  a  specific  and  should  al- 
ways be  used  when  the  loss  of  blood  is  so  great  as  to 
make  it  probable  that  mere  increase  in  the  volume  of 
blood  as  by  normal  salt  solution  or  by  Ringer's  or 
Locke's  solution,  would  not  be  adequate  and  would  not 

3  Hemorrhage  and  Transfusion. 


130  SURGERY    OF    THE    BLOOD-VESSELS. 

leave  enough  corpuscles  to  carry  on  the  vital  functions. 
After  poisoning  from  illuminating  gas  transfusion,  par- 
ticularly when  preceded  by  free  bleeding,  should  be  tried 
if  the  patient  has  not  responded  to  the  usual  remedies. 
Exophthalmic  goiter  is  not  materially  benefited  by  trans- 
fusion. The  shock  and  excitement  may  be  distinctly  in- 
jurious. In  pellagra  the  reported  results  differ.  Some 
authors  advise  transfusion,  but  the  outcome  seems  to  be 
uncertain.  In  pathologic  hemorrhage,  as  hemophilia  or 
purpura,  or  in  hemorrhage  accompanying  jaundice,  trans- 
fusion is  distinctly  indicated  and  is  often  beneficial  and 
even  life  saving.  The  pathology  of  the  blood  in  these 
conditions,  however,  has  not  been  worked  out  and  it  is 
not  fully  known  how  the  transfusion  acts.  In  hemor- 
rhage from  the  newborn,  which  is  supposed  to  be  caused 
by  some  defect  in  the  capillaries,  most  brilliant  results 
have  been  obtained.  In  hemophilia  and  in  hemorrhage 
following  jaundice  good  results  and  sometimes  cures  have 
been  observed  when  other  remedies  had  failed.  Trans- 
fusion for  puerperal  convulsions  has  been  tried,  but  is  of 
doubtful  value,  whereas  frequently  the  ordinary  remedies 
are  followed  by  cure. 

According  to  Eaulston  and  Woodyatt,4  transfusion  of 
blood  in  diabetes  mellitus  gives  unsatisfactory  and  even 
injurious  results. 

The  author's  personal  experience  embraces  transfusion 
in  twenty-two  cases.  All  were  done  by  suture  except  the 
first  in  which  the  Crile  cannula  was  used.  Among  the 
first  series  were  some  unsatisfactory  results  from  a 
mechanical  standpoint,  which  were  largely  due  to  the 
selection  of  too  small  a  vein  and  to  inexperience.  In  the 
cases  of  pellagra  the  disease  was  far  advanced  and  the 

4  Journal  A.  M.  A.,  March  28,    1914. 


TRANSFUSION    OF   BLOOD.  131 

veins  were  thickened.  It  was  difficult  to  get  a  satisfac- 
tory flow  into  the  vein.  This  was  probably  partly  clue  to 
the  terminal  pathology  from  the  disease.  In  other  in- 
stances the  transfusion  technically  has  been  satisfactory, 
and  in  all  recent  cases  there  has  been  no  difficulty  in  in- 
troducing by  this  method  as  much  blood  as  was  thought 
desirable.  Four  transfusions  were  done  for  pellagra  in 
three  patients.  In  no  instance  was  there  any  permanent 
beneficial  result.  Two  transfusions  were  for  sepsis.  In 
one  case,  a  large  perforated  gastric  ulcer  with  general 
peritonitis,  the  patient  was  transfused,  the  ulcer  closed 
and  the  abdomen  drained.  His  condition  was  fairly  good 
after  the  transfusion  and  after  the  operation,  but  he  suc- 
cumbed to  the  peritonitis  within  forty-eight  hours.  It 
was  a  late  case,  the  perforation  having  existed  probably 
for  several  days.  In  another  case  of  sepsis,  following 
injury  to  the  knee  with  suppuration  in  the  femur  and 
thigh  and  profound  sepsis,  transfusion  was  done  after 
amputation  when  the  patient  was  practically  pulseless. 
His  pulse  improved  at  once  and  though  he  had  a  stormy 
convalescence  from  sepsis,  he  eventually  recovered.  His 
recovery  would  hardly  have  been  possible  without  the 
transfusion.  In  three  cases  of  hemorrhage  from  the 
uterus,  transfusion  was  done  and  was  followed  imme- 
diately by  thorough  curettage  in  one  case  and  hyster- 
ectomy in  two.  They  all  recovered.  In  a  case  of 
placenta  previa,  the  patient  had  lost  an  enormous  amount 
of  blood,  the  pulse  at  the  wrist  was  barely  perceptible, 
160,  and  irregular.  She  was  transfused  and  the  condi- 
tion was  entirely  altered.  After  the  blood  flowed  fifteen 
minutes,  the  pulse  came  down  and  normal  color  returned 
to  her  face.  Caesarean  section  was  immediately  per- 
formed. The  abdominal  wound  healed  satisfactorily, 


132  SURGERY   OP    THE    BLOOD-VESSELS. 

but  there  was  sepsis  in  the  uterus.  She  made  a  slow  but 
complete  recovery.  In  a  gastric  hemorrhage,  the  patient 
was  a  man  about  fifty  years  of  age  who  had  been  bleeding 
at  intervals  for  three  days,  vomiting  large  amounts  of 
blood  and  passing  black  stools.  His  hemoglobin  was 
down  to  twenty -five,  and  pulse  rapid  and  weak.  The  pa- 
tient was  transfused  and  a  quick  gastroenterostomy  was 
done  immediately  afterwards  under  ether.  The  pylorus 
was  folded  in.  He  made  a  prompt  convalescence  without 
any  further  bleeding.  In  a  secondary  anemia  in  an  old 
man,  there  was  marked  improvement.  This  transfusion 
was  done  at  the  Mayo  Clinic  at  the  courteous  request  of 
Dr.  Donald  Balfour.  About  a  month  later  Balfour  wrote 
as  follows :  '  *  He  has  improved  wonderfully,  the  hemo- 
globin at  the  present  time  being  seventy-five  percent. 
However,  there  is  more  or  less  uncertainty  about  the  ulti- 
mate outcome  of  the  case,  as  there  seem  to  be  indications 
of  the  condition  being  due  to  carcinoma,  probably  of  the 
body  of  the  stomach. ' ' 

One  transfusion  was  for  pathologic  hemorrhage  from 
hemophilia.  The  history  of  this  case  is  fully  given  on 
page  173.  There  was  temporary  improvement,  but  no 
permanent  benefit.  One  patient  was  transfused  for 
pathologic  hemorrhage  from  chronic  jaundice  without 
benefit  except  to  improve  the  pulse  for  a  day.  The 
hemorrhage  persisted  and  the  patient  died.  A  child  four 
years  old  with  secondary  anemia  following  prolonged  en- 
terocolitis  was  transfused  without  permanent  benefit. 

To  sum  up,  in  anemia  due  to  the  loss  of  normal  blood, 
transfusion  gives  brilliant  results  and  is  practically  a 
specific.  In  secondary  anemia  from  suppuration  often 
excellent  results  can  be  obtained.  When,  however,  the 
anemia  is  due  to  some  toxic  material  in  the  blood  or 
tissues,  as  in  leukemia  or  pernicious  anemia,  transfusion 


TRANSFUSION    OF    BLOOD. 


133 


without  removal  of  the  source  of  the  toxic  material  is  of 
no  avail  and  may  even  be  injurious. 

The  following  table  shows  the  above  cases  classified  : 


SUMMARY  OF  TRANSFUSIONS. 


Disease 


Pellagra 4. 

Uterine  hemorrhage  (hemo 
globin  25  or  under  and  gen 
eral  condition  bad) 

Ruptured  uterus  during  par- 
turition    1. 

Placenta  previa  1. 

Sepsis  ( infected  knee  and 
thigh )  1 . 

Sepsis  (subdiaphragmatic  ah 
scess  from  neglected  appen 
dicitis)  1. 

Sepsis  (large  perforated  gns 
trie  ulcer  and  general  peri- 
tonitis)    1. 

Sepsis  (large  typhoid  perfor- 
ation and  general  peritoni- 
tis)    1. 

Hemorrhage  (suicide,  portal 
vein  divided  by  pistol 
wound)  1. 

Hemorrhage  ( from  throat, 
continuing  a  number  of 
days;  condition  bad) 1. 


j\o.  ot 
Fransfusions 


No.  of 
Patients 


Result 


3.          Xo  benefit. 


3.          All  recovered. 


Recovered  from  imme- 
diate effect.  Died 
about  4  weeks  later 
f  r  o  nil  cholecystitis 
and  edema  of  lungs. 
No  hemolysis. 

Recovery. 


1.         Recovery. 


No  benefit. 


Xo  benefit. 


No  benefit. 


No  benefit. 


Recovery. 


134  SUEGEEY    OF    THE    BLOOD-VESSELS. 

SUMMARY  OF  TRANSFUSIONS. — Continued. 


Disease 

No.  of 
Transfusions 

No.  of 
Patients 

Result 

Hemorrhage      (gastric     ulcer, 
continuing  at  intervals  for 
tliree   days,   hemoglobin   be- 
low 25)    

1. 

1. 

Recovery. 

Noma    of    face     (progressing 
rapidly)     

1 

1 

Xo  benefit. 

Chronic     entero-colitis      (boy, 
aged  4  years  )  

1. 

1. 

Xo  benefit. 

Illuminating  gas   poisoning.  . 

Pathologic  hemorrhage  (jaun- 
dice)      

1. 
1 

1 

Xo  benefit. 
Xo  benefit. 

Pathologic  hemorrhage  (hemo- 
philia)     

1 

1 

Temporary     benefit, 

Secondary    anemia     (probably 
cancer  of  body  of  stomach) 

1. 

I. 

later  death  from  re- 
currence. 

Temporary  benefit. 

None  of  these  transfusions  were  clone  except  as  a  last 
resort.  Of  the  twenty-two  transfusions  on  twenty-one 
patients,  no  benefit  resulted  in  eleven  patients,  temporary 
benefit  in  three  cases,  and  recovery  in  seven  patients. 
When  it  is  considered  that  all  were  desperate  cases  that  in 
the  best  judgment  of  the  operator  would  have  died  with- 
out transfusion  the  complete  recovery  of  one-third  of  the 
patients  (seven)  with  temporary  benefit  in  three  others  is 
gratifying. 


CHAPTER  VIII. 
HEMORRHAGE. 

Hemorrhage  is  one  of  the  most  important  features  of 
surgical  practice  and  in  some  form  is  met  in  every  branch 
of  medicine.  A  thorough  comprehension  of  the  causes 
of  hemorrhage  and  the  methods  of  treating  it  is  neces- 
sary for  both  the  surgeon  and  the  general  practitioner. 
Bleeding  may  be  divided  into  hemorrhage  resulting  from 
a  local  lesion  of  a  blood-vessel  when  the  blood  itself  is 
normal;  and  pathologic  hemorrhage,  where  the  chief,  if 
not  the  only,  cause  is  some  alteration  of  the  blood,  or  a 
constitutional  disease  of  the  capillaries.  The  first  may 
be  subdivided  into  hemorrhage  from  direct  trauma  and 
that  due  to  a  local  lesion  of  the  vessel  from  disease,  such 
as  hemorrhage  from  ulcer  of  the  stomach,  or  ulcer  of  the 
bowel.  Hemorrhage  under  either  of  these  heads  is 
treated  along  the  same  lines,  but  in  pathologic  hemor- 
rhage different  problems  arise. 

The  symptoms  of  hemorrhage  are  either  obvious  from 
the  flowing  of  blood  externally,  or  the  blood  may  be  con- 
cealed in  one  of  the  large  body  cavities  or  in  the  tissues. 
Diagnosis  of  concealed  hemorrhage  often  presents  con- 
siderable difficulty,  particularly  if  it  is  accompanied  by 
a  trauma  that  may  at  the  same  time  be  a  cause  of  shock. 
In  both  concealed  hemorrhage  and  in  shock  the  general 
symptoms  are  practically  the  same.  Concealed  hemor- 
rhage may  be  quite  extensive  before  any  symptoms  are 
manifested.  Hemorrhage  in  special  areas,  as  in  the 
brain,  may  cause  serious  symptoms  and  even  death,  due, 

135 


136  SURGERY    OF    THE    BLOOD-VESSELS. 

not  to  the  amount  of  blood  lost,  but  to  the  location  of  the 
clot.  Symptoms  from  hemorrhage  resemble  those  of 
shock  so  closely  because  in  each  instance  the  vascular 
system  is  suffering  from  a  lack  of  blood.  In  hemorrhage 
it  has  gone  outside  of  the  vascular  system,  whereas  in 
shock  the  great  dilatation  of  the  internal  blood-vessels 
makes  the  space  larger  than  the  blood  can  fill.  The  symp- 
toms also  depend  upon  whether  the  blood  is  lost  sud- 
denly, for  a  small  amount  bled  quickly  will  produce  more 
disturbance  than  a  larger  quantity  if  gradually  lost. 
Frequently  the  patient  faints  in  external  hemorrhage 
solely  from  psychic  causes.  The  blood  pressure  falls 
rapidly  in  marked  bleeding.  The  patient  is  usually  anx- 
ious, prostration  begins,  the  hands  and  feet  are  cold,  and 
the  surface  is  chilled  and  clammy.  The  skin  becomes 
pale  or  even  bluish,  and  the  pulse  is  quickened.  The 
temperature  falls  steadily  and  soon  is  subnormal,  even  if 
the  patient  has  fever.  Breathing  is  short,  sighing  and 
distressed.  Cold  sweat  appears  on  the  forehead,  chest, 
and  the  palms  of  the  hands.  Frequently  the  patient 
yawns  and  becomes  restless.  Thirst  is  a  prominent  fea- 
ture. If  the  patient  attempts  to  sit  up  he  often  falls 
back  in  syncope,  which  is  not  psychic,  but  due  to  lowered 
blood  pressure.  As  the  hemorrhage  increases  the  pulse 
becomes  irregular  and  respirations  are  shallow.  The 
skin  assumes  a  waxy  hue,  the  pupils  dilate,  and  the  mouth 
tends  to  gape.  There  is  often  muscular  twitching.  The 
patient  may  become  unconscious,  or  may  complain  of 
vertigo.  There  may  be  nausea  and  vomiting.  Roaring 
sounds  are  sometimes  heard  in  the  ears.  Dark  specks  or 
flashes  of  light  may  be  seen.  The  sphincters  are  relaxed. 
Often  it  is  necessary  to  differentiate  between  internal 
hemorrhage,  as  in  the  abdominal  cavity,  and  shock. 
While  the  symptoms  naturally  are  not  unlike,  there  are 


HEMORRHAGE.  137 

certain  distinguishing-  features  that  may  aid  in  a  diag- 
nosis. The  history  of  the  case  is  important,  particularly 
as  to  whether  the  injury  would  be  more  likely  to  cause 
hemorrhage  or  shock.  '  An  injury  from  a  bullet  or  stab 
wound  would  be  more  apt  to  cause  hemorrhage  than 
shock,  whereas  a  crushing  injury  might  cause  hemor- 
rhage, but  would  probably  produce  shock. 

According  to  Crile,  two  facts  stand  out  clearly  in  the 
clinical  differentiation  between  shock  and  hemorrhage. 
The  first  is  that  there  is  usually  a  primary  state  of  ex- 
citement in  hemorrhage,  which  is  absent,  as  a  rule,  in 
shock;  and,  secondly,  the  pulse  rate  in  hemorrhage  is  al- 
ways increased,  whereas  in  shock  it  is  usually  increased, 
but  may  be  decreased  in  frequency.  One  of  the  most  im- 
portant means  of  differentiating  between  shock  and 
hemorrhage  is  by  examination  of  the  blood.  According 
to  Crile,  when  hemorrhage  occurs,  blood  examinations  will 
show  a  fall  in  the  number  of  red  cells,  a  decrease  in  the 
hemoglobin,  and  an  increase  in  the  white  cells.  The 
maximum  increase  occurs  early.  In  shock,  however, 
there  is  no  fall  in  the  hemoglobin,  or  in  the  red  cells  and 
no  increase  in  the  white  cells.  The  observations  of  Crile 
on  patients  who  had  acted  as  donors  in  transfusion  tallies 
very  closely  with  his  experiments  on  lower  animals,  so  the 
findings  of  a  blood  analysis  in  the  differentiation  between 
shock  and  hemorrhage  may  be  regarded  as  based  on  both 
clinical  and  experimental  observations. 

Treatment. 

Treatment  of  hemorrhage  due  either  to  a  trauma  of  the 
vessel  by  mechanical  force  or  to  a  lesion  produced  by 
local  disease  is  identical.  Treatment  may  be  either  local 
or  general,  and  frequently  measures  have  to  be  adopted 
with  considerable  nicety  of  judgment.  For  instance,  one 


138  SUEGERY    OF    THE    BLOOD-VESSELS. 

of  the  general  phenomena  of  hemorrhage  is  the  lowering 
of  blood  pressure.  This  may  be  taken  as  nature's  method 
to  promote  clotting  and  stop  the  hemorrhage.  If  stim- 
ulants are  administered  too  vigorously,  either  in  the 
form  of  drugs  that  raise  the  blood  tension,  or  by  filling 
up  the  vascular  system,  as  with  salt  solution,  the  hemor- 
rhage may  actually  be  made  worse.  On  the  other  hand, 
if  the  blood  pressure  is  permitted  to  fall  too  low,  the  pa- 
tient may  die  from  syncope. 

The  method  of  decreasing  the  blood  pressure  to  the 
region  that  is  bleeding,  provided  it  does  not  involve  vital 
centers,  has  the  advantage  of  checking  the  hemorrhage 
without  the  disadvantage  that  would  accrue  to  a  low  blood 
pressure  in  a  vital  part.  If  the  hemorrhage  results  from 
a  small  wound,  efforts  should  be  made  to  control  the 
bleeding  point  directly.  When  the  bleeding  comes  from 
a  large  vessel  in  a  small  wound,  pressure  with  the  fingers 
on  the  injured  vessel  will  stop  the  hemorrhage.  A.  P. 
Gerster  reports  a  case  in  which  a  butcher  accidentally 
wounded  his  femoral  arteiy  with  a  sharp  knife.  Gerster 
happened  to  be  present  and  immediately  inserted  his 
finger  into  the  wound,  thereby  controlling  the  bleeding 
until  the  patient  could  be  anesthetized  and  the  artery 
tied.  While  it  is  desirable  to  use  as  much  asepsis  and 
cleanliness  as  possible,  in  injuries  of  large  vessels  death 
will  soon  occur  unless  the  hemorrhage  is  promptly 
checked  and  time  cannot  be  lost  for  any  other  considera- 
tion. If  bleeding  is  not  severe,  other  measures  can  be 
adopted.  One  of  the  most  important  therapeutic  agents 
is  changing  the  position  of  the  bleeding  part.  If  bleed- 
ing comes  from  the  head,  the  head  should  be  elevated  and 
if  from  the  arm  or  leg  the  affected  limb  is  raised.  This 
very  materially  decreases  hemorrhage.  Flexion  of  the 


HEMORRHAGE.  1I59 

arm  or  leg  in  addition  to  elevation  will  reduce  the  local 
blood  pressure  still  more. 

Pressure  is  one  of  the  most  effective  methods  of  deal- 
ing with  hemorrhage.  Pressure  can  be  applied  directly 
or  indirectly.  Direct  pressure  upon  the  bleeding  part  is 
very  effective.  It  is  often  better  than  the  blind  applica- 
tion of  a  clamp. 

W.  J.  Mayo  speaks  of  several  instances  in  which  the 
renal  artery  retracted  from  the  pedicle  after  nephrec- 
tomy,  or  was  injured  during  operation,  and  he  promptly 
controlled  the  hemorrhage  by  grasping  the  artery  with 
his  fingers.  In  such  a  large  vessel,  pulsations  can  be 
easily  felt  and,  as  Mayo  says,  the  artery  "fairly  jumps 
into  the  fingers,"  whereas  the  blind  application  of  forceps 
in  a  bloody  field  may  do  great  damage.  After  the  vessel 
has  been  caught  in  the  fingers  forceps  are  accurately  ap- 
plied. 

Indirect  pressure  to  control  hemorrhage  may  consist 
either  of  direct  pressure  over  the  main  trunk  of  the  artery 
that  leads  to  the  bleeding  point,  or  a  constriction  of  the 
whole  limb  by  a  tourniquet.  Indirect  pressure  is  best 
made  in  emergency  by  the  intelligent  application  of  the 
hand  or  fingers.  Occasionally  a  strong  truss  pad  might 
suffice.  The  method  of  controlling  the  larger  arteries  by 
simple  pressure  with  the  fingers  is  shown  in  the  accom- 
panying illustrations.  (Figs.  58,  59,  60,  and  61.)  Even 
the  abdominal  aorta  may,  according  to  McEwen's  method, 
be  compressed  and  if  the  circulation  is  not  entirely 
stopped  often  the  blood  pressure  is  so  lowered  that  a  clot 
may  form.  It  must  be  remembered  that  the  character 
of  the  blood  rapidly  changes  after  hemorrhage  and  the 
disintegration  of  the  platelets.  Unless  the  hemorrhage 
is  pathologic,  clotting  will  take  place  more  readily  after 


140 


SURGERY    OF    THE    BLOOD-VESSELS. 


bleeding  has  already  occurred,  provided  some  assistance 
is  given  nature. 

A  tourniquet  is  most  valuable  in  controlling  hemorrhage 
in  the  extremities.  The  tourniquet  now  usually  employed 
is  an  elastic  rubber  band  or  tube.  Before  applying  it  the 
leg  or  arm  should  be  elevated  and  the  typical  Esmarch 
bandage  may  be  used  before  tightening  the  tourniquet. 


Fig.    58. — Digital    compression    of    carotid    artery.       (Marwedel.) 

The  tourniquet  should  not  be  too  near  a  joint,  but  prefer- 
ably on  the  muscular  part  of  the  thigh  or  arm.  It  must 
be  tightened  quickly  because  if  first  loosely  applied,  it 
will  merely  constrict  the  venous  circulation  and  produce 
a  venous  hyperemia,  whereas  if  quickly  tightened  both 
the  venous  and  the  arterial  blood  will  be  cut  off  at  the 
same  time.  A  tourniquet  should  not,  as  a  rule,  be  left 


HEMORRHAGE. 


on  much  more  than  an  hour.  If  it  remains  on  longer 
than  an  hour  in  elderly  people  with  bad  arteries,  there 
may  be  gangrene  of  the  limb,  though  in  younger  persons 
it  can  be  kept  on  several  hours  if  necessary.  Frequently 
the  unskillful  application  of  a  tourniquet  may  result  dis- 
astrously and  by  not  being  tight  enough  it  may  cause 
more  bleeding  than  if  no  tourniquet  at  all  had  been  used. 


Fig.   59. — Digital    compression    of    subdavian    artery.      (Marwedel. ) 

Momburg  even  places  a  tourniquet  around  the  abdomen 
to  constrict  the  abdominal  aorta.  The  waist  of  the 
patient  is  encircled  by  a  heavy  rubber  tube  midway  be- 
tween the  crest  of  the  ileum  and  the  costal  arch.  The 
tube  should  be  one-half  inch  in  diameter  and  very  elastic 
and  should  be  wound  around  the  trunk  several  times  until 
pulsations  in  the  femoral  are  arrested.  This  should  not 


142 


SURGERY    OF    THE    BLOOD-VESSELS. 


be  done  until  the  patient  is  completely  relaxed  under  a 
general  anesthetic.  The  Esmarch  bandage  had  best  be 
placed  on  the  legs  just  before  using  this  tourniquet. 
The  bowels  should  be  well  emptied  before  the  operation 
and  the  tourniquet  should  be  put  on  with  the  patient  in 
the  Trendelenburg  position  so  the  intestines  will  not  be 
too  greatly  constricted.  This  method  has  been  advised 


Fig.   60. — Compression    of   brachial    artery.      (Marwedel.) 

in  hemorrhage  from  the  uterus  and  may  be  used  in  an 
emergency,  though  it  is  by  no  means  free  from  dan- 
ger. 

Often  the  gradual  binding  of  the  entire  limb  from  the 
distal  extremity  toward  the  trunk  will  modify  hemor- 
rhage. This,  of  course,  is  quite  different  from  a  loosely 
applied  tourniquet,  as  the  compression  extends  over  the 
whole  of  the  limb  and  it  is  not  possible  to  produce  venous 


SEMOKRHAGE. 


143 


hyperemia  in  this  way.  To  show  how  effective  it  is  in 
combination  with  elevation,  John  A.  Wyeth,  of  Xc\v 
York,  often  amputates  the  lower  part  of  the  foot  or  ankle, 
sutures  the  flap,  but  does  not  tie  the  vessels,  relying 
upon  the  elevated  position  and  the  firm  application  of  a 
bandage  over  an  abundant  amount  of  cotton  which  will 


Fig.   61. — Compression    of    femoral    artery.      (Marwedel.) 

produce  elastic  and  uniform  pressure  from  the  stump  to 
above  the  knee. 

Pressure  can  also  be  applied  by  a  tampon.  The 
tampon  should  consist  of  strips  of  sterile  or  antiseptic 
gauze  that  are  systematically  packed  firmly  to  fit  every 
irregularity  of  the  wound.  The  form  recommended  by 
Mikulicz  is  the  best  in  a  large  wound.  Here  one  or  two 


144  SUKGERY    OF    THE    BLOOD-VESSELS. 

layers  of  gauze  are  spread  over  the  wound  and  strips  are 
packed  on  the  gauze.  In  this  manner  the  packing  can  be 
readily  removed  and  the  pressure  is  somewhat  more 
equally  distributed. 

Heat  is  one  of  the  most  satisfactory  local  remedies  in 
hemorrhage.  It  may  be  applied  in  the  form  of  hot  water 
or  metal  heated  as  the  Paquelin  cautery,  or  as  the 
plumber's  soldering  iron,  or  by  electricity,  as  the  electric 
cautery. 

Downes  devised  a  clamp  containing  an  electric  cau- 
tery which  is  used  by  several  surgeons  instead  of  liga- 
tures. The  heat  of  the  cautery  should  not  be  too  great 
if  the  effort  is  solely  to  control  hemorrhage,  else  the 
vessels  may  be  cut  through  as  with  a  knife.  If  very  hot 
water  is  used  its  action  should  be  limited  to  a  local  area ; 
otherwise  its  temperature  should  not  exceed  120 =  .  Above 
this  point  damage  is  readily  done  to  the  tissue.  Water 
at  115°  will  usually  control  ordinary  bleeding  from  small 
points.  If  the  action  of  boiling  water  can  be  limited, 
as  by  wringing  cloths  out  of  boiling  water  and  applying 
for  a  few  minutes  to  a  small  wound,  generally  no  damage 
results.  A  temperature  of  115°  to  120°  can  be  maintained 
for  some  time  without  any  serious  injury  to  the  tissues. 
Occasionally,  as  in  bleeding  from  the  uterus,  when  even 
hot  water  does  not  control,  the  injection  of  a  spray  of 
steam  will  stop  the  bleeding.  Extensive  sloughing  may 
follow  this  procedure  and  it  should  not  be  used  unless 
no  other  measure  seems  effective.  It  is  particularly 
suitable  in  the  uterus,  as  steam  may  be  introduced  into 
the  uterine  cavity  through  a  tube  that  contains  a  num- 
ber of  openings.  It  is  called  "atmokausis." 

Cold  occasionally  makes  a  satisfactory  hemostatic 
agent.  It  is  not  so  good  as  heat  and  tends  to  depress  the 
vitality  of  the  tissues  if  long  maintained.  Cold  also  re- 


HEMORRHAGE.  145 

tards  coagulation.  It  is  of  service  in  certain  instances, 
as  in  hemorrhage  of  the  gums.  Where  considerable 
bleeding  is  expected,  freezing  the  sockets  of  the  tooth 
and  the  gum  with  a  spray  of  ethyl-chloride  is  often 
effective  when  the  hemorrhage  would  otherwise  be  very 
troublesome.  This  procedure  has  been  particularly 
recommended  in  extracting  a  tooth  in  one  who  is  prob- 
ably hemophilic.  The  application  of  gelatin  has  been  ad- 
vised by  some,  but  it  is  of  doubtful  value. 

Bleeding  from  bone  may  be  checked  by  the  applica- 
tion of  Horsley's  wax,  a  preparation  devised  by  Sir  Vic- 
tor Horsley.  It  consists  of  beeswax  seven  parts,  al- 
mond oil  one  part,  and  salicylic  acid  one  part.  The  mix- 
ture is  firmly  pressed  into  the  surfaces  of  the  bleeding 
bone.  The  wTax  is  antiseptic  and  is  well  borne  by  the 
tissues.  It  acts  by  filling  up  the  cavities  in  which  the 
bleeding  vessels  lie.  Another  very  effective  method  is 
the  application  of  a  bit  of  muscle.  If  hemorrhage  from 
an  injured  skull  cannot  be  controlled  otherwise,  a  piece  of 
muscle  can  be  cut  from  the  temporal  muscle  and  pressed 
upon  the  bleeding  spot.  In  the  brain  a  small  piece  of 
muscle  laid  on  the  bleeding  area  often  stops  the  hemor- 
rhage promptly.  It  is  probable  that  muscular  tissue 
contains  a  considerable  amount  of  thrombokinase,  which 
hastens  clotting. 

The  treatment  of  traumatic  hemorrhage  by  other  than 
local  measures  consists  in  the  administration  of  such 
drugs  or  remedies  as  may  tend  to  keep  up  the  blood  pres- 
sure if  it  seems  to  be  falling  to  an  alarming  extent. 
Suprarenal  extract  contracts  the  peripheral  vessels  and 
raises  the  blood  pressure.  It  is,  however,  a  dangerous 
drug  unless  carefully  used  and  should  be  administered 
cautiously  and  in  small  doses.  Its  action  is  evanescent. 
Bandaging  the  extremities  drives  more  blood  to  the  vital 


146  SURGERY    OF    THE    BLOOD-VESSELS. 

centers  and  increases  blood  pressure.  Morphine  is  one 
of  the  most  satisfactory  heart  stimulants  and  at  the  same 
time  quiets  the  restless  patient.  Strychnine  and  digitalis 
are  recommended  by  many  authors. 

Hypodermoclysis  in  hemorrhage  is  valuable.  Normal 
salt  solution,  nine-tenths  of  one  percent  sodium  chloride, 
or  Ringer's  or  Locke's  solution  may  be  used.  Gravity  is 
the  most  satisfactory  method  of  introducing  it.  The  skin 
should  not  be  permitted  to  become  tense,  as  necrosis  may 
occur.  Where  haste  is  not  too  important,  hypodermo- 
clysis  will  often  be  most  beneficial  and  may  be  given 
in  several  portions  of  the  body  at  the  same  time.  The 
skin  can  be  readily  sterilized  by  tincture  of  iodine  and  a 
sterile  aspirating  needle  introduced  well  beneath  the  skin 
or  under  the  mammary  gland.  The  needle  should  be  held 
in  place  by  antiseptic  adhesive  plaster. 

The  use  of  intravenous  infusion  sometimes  gives 
prompt  results  when  the  case  is  urgent.  A  blunt  in- 
travenous needle  with  a  glass  irrigator  and  connecting 
tube  are  sterilized.  The  vein  selected  should  be  near  the 
elbow  and  is  rendered  prominent  by  slight  pressure  upon 
the  arm,  or  by  cording  the  arm  sufficiently  to  bring  out 
the  vein.  The  skin  is  cleaned  and  infiltrated  with  novo- 
caine  or  a  weak  solution  of  cocaine.  The  skin  over  the 
vein  is  caught  with  thumb  forceps,  lifted  up,  and  with 
sharp  scissors  the  portion  of  the  skin  in  the  grasp  of  the 
forceps  is  cut  off.  This  leaves  an  oval  wound  which  fully 
exposes  the  vein.  It  is  impossible  to  wound  the  vein  or 
lift  it  up  in  this  manner.  A  few  strokes  of  the  knife  or 
the  scissors  then  readily  frees  the  vein.  It  is  ligated  be- 
low, and  part  of  its  wall  just  above  the  ligature  caught 
with  a  mosquito  forceps.  With  sharp  scissors  an  oblique 
cut  is  made  about  one-half  way  through  the  caliber  of 
the  vein,  and  the  intravenous  needle  is  introduced  with 


HEMORRHAGE.  147 

the  solution  flowing.     If  the  needle  is  not  available,  a 
medicine-dropper  will  serve  every  purpose. 

According  to  Crile,  most  pathologists  at  large  hospitals 
point  to  cases  where  intravenous  infusion  has  been  used 
without  benefit  and  which  show,  on  post-mortem  examina- 
tion, edema  of  many  organs  with  free  fluid  in  the  body 
cavities.  Not  more  than  three  or  four  pints  of  solution 
should  be  used,  usually  one-half  of  that  quantity  is  all 
that  is  necessary.  A  larger  amount  tends  to  embarrass 
the  heart,  and  may  cause  dilatation  of  the  heart,  or  else 
rapidly  leaves  the  vessels,  passing  into  the  tissues  or 
into  the  bowel,  or  through  the  kidneys.  About  three 
cubic  centimeters  per  minute  is  sufficient,  and  never  more 
than  a  quart  should  be  given  in  fifteen  minutes.  Where 
marked  shock  accompanies  the  hemorrhage,  injection  of 
suprarenal  extract  into  the  salt  solution  raises  the  blood 
pressure  quickly.  It  may  be  mixed  with  the  saline  solu- 
tion or  injected  in  a  stronger  solution  from  a  hypodermic 
syringe,  the  needle  of  which  is  thrust  into  the  rubber 
tube  of  the  irrigator.  At  the  slightest  evidence  of  dila- 
tation of  the  heart  the  patient  should  be  put  in  as  near  a 
vertical  position  as  possible  and  massage  made  over  the 
heart.  The  best  solution  for  intravenous  use  is  either 
normal  salt  solution,  nine-tenths  of  one  percent,  prefer- 
ably made  of  distilled  water,  and,  of  course,  sterilized, 
or  Ringer's  or  Locke's  solution.  The  formula  for 
Ringer's  solution  is  sodium  chloride,  0.7  percent;  potas- 
sium chloride,  0.03  percent ;  calcium  chloride,  0.025  per- 
cent in  distilled  water.  Locke's  solution,  which  is  by 
some  considered  better,  consists  of  sodium  chloride,  0.9 
percent ;  calcium  chloride,  0.024  percent ;  potassium  chlor- 
ide, 0.042  percent;  sodium  bicarbonate,  0.01  to  0.03  per- 
cent ;  glucose,  0.1  percent  in  distilled  water.  These  solu- 
tions are  introduced  at  a  temperature  between  115°  and 


148  SUEGERY    OF    THE    BLOOD-VESSELS. 

120 J  as  the  effect  of  the  heat  upon  the  heart  is  very  stim- 
ulating. 

Transfusion  of  blood  is  indicated  in  any  ease  of  hemor- 
rhage in  which  the  hemoglobin  is  so  low  that  it  is  doubt- 
ful whether  enough  corpuscles  are  left  to  perform  the 
vital  function  of  carrying  oxygen.  Crile  has  pointed  out 
that  in  shock,  after  severe  hemorrhage,  and  in  certain 
other  conditions  where  it  was  formerly  thought  no 
pathology  could  be  found,  a  careful  examination  of  the 
brain  shows  destruction  of  the  cortical  cells.  If  the 
hemorrhage  is  severe  or  if  the  anemia  is  prolonged  many 
of  these  cells  are  permanently  injured.  So,  even  if  a 
patient  barely  escapes  with  his  life  after  a  severe  hemor- 
rhage, there  may  be  such  permanent  damage  to  the 
cortical  cells  of  the  brain  as  to  make  it  impossible  for 
him  ever  to  recover  fully.  Many  so-called  neuras- 
thenics may  be  explained  in  this  way.  It  has  been  shown 
that  a  dog  can  be  killed  by  strangulation  and  resusci- 
tated by  injection  of  normal  salt  solution  with  a  small 
amount  of  suprarenal  extract  into  an  artery,  the  injec- 
tion being  directed  toward  the  heart.  Pressure  thus  in- 
duced in  the  coronary  arteries  will  sometimes  start  the 
heart,  even  after  the  dog  has  been  dead  seven  minutes. 
The  animal,  however,  does  not  live  long  if  he  is  resusci- 
tated after  seven  minutes.  After  being  dead  only  one  or 
two  minutes  the  animal  may  survive  indefinitely.  An  in- 
teresting point  is  that  after  the  longer  periods  resuscita- 
tion is  followed  by  very  incomplete  function.  The  dog 
is  blind  and  deaf  and  cannot  use  any  of  the  higher  senses. 
A  shorter  period  is  followed  by  retention  of  only  some  of 
the  special  senses,  and  a  still  shorter  period  will  prob- 
ably result  in  the  loss  merely  of  certain  recently  ac- 
quired tricks  that  the  dog  formerly  knew.  In  other 
words,  it  seems  that  a  nonfatal  anemia  of  the  brain, 


HEMORRHAGE.  14! » 

whether  partial  or  complete,  extending  over  a  consider- 
able period  of  time,  may  cause  degeneration  of  an  ab- 
normal amount  of  cortical  cells,  with  resulting  symptoms 
such  as  loss  of  memory,  inability  to  collect  thoughts, 
groundless  fears,  etc. 

Aside  from  the  treatment  that  has  been  outlined,  the 
usual  efforts  for  maintaining  vital  energy  are  employed 
as  in  shock.  Cold  should  never  be  used  to  stop  bleeding 
when  the  general  vitality  of  the  patient  is  low. 

The  hemorrhage  that  occurs  during  surgical  operations 
may  be  considered  in  separate  detail.  One  of  the  most 
important  things  is  prophylaxis.  Careful  hemostasis, 
stopping  each  bleeding  point  and  operating  in  a  dry  field, 
is  the  ideal.  Sometimes  this  ideal  cannot  be  attained. 
Where  hemorrhage  is  unavoidable,  as  in  the  separation  of 
massive  adhesions,  it  is  best  to  proceed  as  quickly  as  pos- 
sible so  the  bleeding  surface  may  be  exposed  and  sub- 
jected to  the  pressure  of  gauze.  In  dealing  with  hemor- 
rhage in  operations,  we  must  consider  not  only  the  im- 
mediate bleeding  that  occurs  during  the  operation,  but 
what  occurs  subsequent  to  operation,  which  is  often  just 
as  important.  In  the  extremities  a  bloodless  field  can  be 
maintained  by  the  application  of  a  tourniquet.  A  tourni- 
quet is  followed  by  oozing  and  often  the  amount  of  blood 
that  escapes  after  operation  is  considerable.  When  a 
dissection  on  an  extremity  necessitates  a  perfectly  dry 
field  a  tourniquet  should  be  used,  the  limb  being  first  ele- 
vated or  the  Esmarch  bandage  applied  from  the  ex- 
tremity of  the  limb  toward  the  body,  and  then  an  elastic 
tourniquet  is  quickly  adjusted.  For  ordinary  purposes, 
however,  it  is  frequently  best  to  dispense  with  the  tourni- 
quet and  carefully  check  the  bleeding  as  it  occurs  by  seiz- 
ing the  small  vessels  with  hemostats  and  ligating  the 
large  vessels  before  dividing  them.  After  an  operation 


150  SURGERY    OF    THE    BLOOD-VESSELS. 

of  this  nature  there  is  practically  no  after  oozing,  and 
the  vitality  of  the  tissues  is  not  affected  by  depriving 
them  of  the  circulation  of  the  blood  as  is  the  case  when 
the  tourniquet  is  used.  Undoubtedly,  the  application  of 
a  tourniquet  has  been  much  abused.  Maintaining  the  re- 
sistance of  the  tissues  by  gentleness  and  careful  hemo- 
stasis  and  by  preserving  the  circulation  of  the  blood,  is 
almost  as  important  in  preventing  infection  as  careful 
asepsis.  Too  much  delay  and  indiscriminate  clamping, 
on  the  other  hand,  create  trauma,  which  is  often  un- 
necessary and  always  undesirable.  The  operator  should 
try  to  control  bleeding  without  excessive  injury  to  the 
tissues,  and  at  the  same  time  without  delaying  the  oper- 
ative procedure  unduly.  In  patients  whose  vitality  is 
very  low,  as  in  sufferers  from  extensive  tuberculosis  of 
the  bone,  the  application  of  a  tourniquet  is  unwise. 
These  individuals  are  emaciated  and  stand  trauma  badly. 
Their  tissues  also  have  little  resistance.  A  tourniquet 
here  produces  considerable  shock  and  the  pressure  on  the 
muscles,  blood-vessels,  and  nerves  causes  additional 
trauma,  and  is  followed  by  marked  oozing.  Depriving 
the  tissues  of  blood  by  a  tourniquet  during  the  operation 
also  lowers  their  resistance.  The  author  has  on  two 
occasions  amputated  the  hip  joint  without  a  tourniquet, 
by  the  dissecting  method,  clamping  or  tying  the  large 
vessels  in  the  course  of  the  incision  before  they  were 
cut.  It  is  surprising  how  much  less  shock  there  is  and 
how  much  more  promptly  the  tissues  healed  under  such 
treatment  than  after  the  application  of  a  tourniquet. 

In  operations  about  the  head  and  neck,  posture  is  an 
excellent  means  of  lessening  hemorrhage.  The  seques- 
tration anemia  of  Dawbarn,  is  also  of  service  here.  He 
applies  a  tourniquet  on  all  the  extremities  close  to  the 
body  just  tightly  enough  partially  to  obstruct  the  venous 


HEMORRHAGE.  151 

return,  but  not  to  occlude  the  arteries.  Tims  passive  con- 
gestion of  all  the  extremities  is  produced  and  blood  is 
stored  up.  The  blood  pressure  is,  consequently,  lowered 
and  there  is  much  less  bleeding  in  the  operative  field. 
The  head  and  neck  should  be  elevated.  Care  must  be 
taken,  however,  to  prevent  syncope  which  may  follow  if  a 
too  erect  position  is  maintained  and  particularly  if 
chloroform  is  the  anesthetic. 

The  operator  should  learn  that  he  can  control  any 
hemorrhage  in  the  vast  majority  of  instances  if  he  will 
keep  cool  and  use  common  sense.  In  such  accidents  as 
the  retraction  of  the  renal  artery  from  its  pedicle  the 
artery  can  be  felt  and  grasped  with  the  fingers.  In  a  sud- 
den hemorrhage,  which  usually  comes  from  one  point, 
the  fingers  are  the  best  temporary  means  of  controlling 
the  bleeding.  If  it  is  a  venous  hemorrhage,  packing 
should  be  used  and  firm  pressure.  The  packing  is  re- 
moved a  little  at  a  time  until  the  bleeding  points  are  iso- 
lated and  clamped.  Tampons  for  the  permanent  con- 
trol of  hemorrhage  should  rarely  be  employed,  particu- 
larly if  the  bleeding  is  arterial. 

In  hemorrhage  during  operations  upon  the  bladder, 
hot  water  is  useful.  Sometimes,  when  a  wide  exposure 
has  been  made  the  bleeding  point  may  be  seen  and 
sutured,  but  generally  bleeding  from  the  bladder  can  be 
controlled  temporarily  by  firm  pressure  with  dry  gauze 
or  with  gauze  wrung  out  of  very  hot  water  until  irriga- 
tion is  begun.  The  irrigation  consists  of  a  constant  in- 
flow of  water  at  a  temperature  at  about  115°  F.  through 
a  catheter  in  the  penis  in  suprapubic  operations.  The 
outflow  is  provided  for  by  a  larger  tube  in  the  wound, 
which  can  also  carry  off  small  clots.  This  may  run  from 
twelve  to  forty-eight  hours  and  is  discontinued  when  the 
return  flow  is  entirely  clear  for  several  hours.  The 


152  SURGERY    OF    THE    BLOOD-VESSELS. 

hemorrhage  is  not  only  controlled  but  the  irrigation  of 
warm  water  seems  to  have  a  beneficial  effect  upon  the 
secretion  of  urine  (page  163). 

The  local  application  of  drugs  such  as  suprarenal 
preparations,  gelatin,  antipyrin,  and  the  iron  salts  in  Mon- 
sel's  solution  is  but  seldom  indicated  in  ordinary  hemor- 
rhage. Compound  alum  powder  ( Squibb 's  surgical 
powder)  may  sometimes  be  employed  as  it  is  antiseptic. 
A  small  gauze  bag  may  be  filled  with  this  powder  and  put 
in  the  wound.  In  most  operations,  however,  such  reme- 
dies are  hardly  justifiable. 

Treatment  of  Special  Hemorrhage. 

Hemorrhages  often  require  remedies  that  are  pecu- 
liarly suited  to  the  regions  from  which  the  bleeding 
comes.  These  regions  may  be  divided  into  the  head, 
neck,  extremities,  chest,  and  abdomen. 

Hemorrhage  from  wounds  of  the  scalp  is  very  common. 
The  anatomy  of  the  scalp  renders  it  difficult  to  clamp  and 
ligate  the  individual  vessels.  The  bleeding  can  be  satis- 
factorily controlled  by  passing  a  suture  under  the  vessel. 
This  is  done  while  the  wound  is  being  closed.  Care 
should  be  taken  to  tie  the  ligature  just  tight  enough  to 
stop  the  bleeding,  as  too  great  constriction  may  result 
not  only  in  necrosis  but  in  secondary  hemorrhage.  With 
a  sharp  needle  and  iodized  catgut  bleeding  from  the  scalp 
may  be  quickly  controlled.  A  continuous  button-hole 
stitch  should  be  used,  carefully  adjusting  the  tension  on 
each  stitch.  When  the  bleeding  is  from  bone,  pressure 
with  a  gauze  sponge  may  check  it.  If  it  does  not,  the 
bone  can  sometimes  be  crushed  with  heavy  forceps.  One 
of  the  most  satisfactory  remedies  is  to  cut  a  piece  of 
muscle  from  the  nearby  tissue,  usually  from  the  temporal 
muscle,  and  rub  it  firmly  into  the  bleeding  spot.  The 


HEMOERHAGE.  1  .")•') 

wax  of  Sir  Victor  Horsley  may  be  used  (see  page  14.")). 
If  the  bleeding  comes  from  the  dura,  it  is  controlled  by 
sutures  of  fine  silk  or  catgut.  Bleeding  from  the  surface 
of  the  brain,  if  profuse,  may  be  stopped  by  passing  fine 
catgut  in  a  small  needle  under  the  bleeding  vessels.  The 
ligature  is  tied  with  just  enough  tension  to  cheek  the 
bleeding.  If  a  large  vessel  is  not  involved  the  applica- 
tion of  a  small  bit  of  muscle  tissue  may  suffice.  The 
general  rule  of  dealing  as  gently  as  possible  with  brain 
tissue  and  never  touching  it  unnecessarily  should  always 
be  remembered.  Some  surgeons  advocate  constant  irri- 
gation of  the  surface  of  the  brain  during  operation  with 
salt  solution  or  even  with  an  antiseptic.  Bleeding  should 
be  controlled  without  leaving  any  packing  or  gauze  on 
the  cortex  of  the  brain. 

Bleeding  from  the  face,  if  not  very  profuse,  can  usually 
be  stopped  by  pressure.  The  arteries  of  the  face  are  so 
richly  supplied  with  muscle  and  are  so  ready  to  respond 
to  dilatation  or  contraction,  that  they  contract  power- 
fully and  under  a  comparatively  slight  stimulant.  A 
hemostat  left  on  a  large  artery  of  the  face  for  a  few 
minutes  will  often  occlude  it.  However,  it  is  best  to  li- 
gate  a  vessel  of  importance  by  passing  a  suture  under- 
neath it.  Here,  as  elsewhere,  catgut  is  the  most  desir- 
able material.  Bleeding  from  the  nose  ordinarily  ceases 
without  trouble  but  sometimes  demands  the  best  re- 
sources of  the  surgeon.  Occasionally,  in  recurrent 
hemorrhage  from  the  nose,  the  bleeding  spot  can  be  lo- 
cated on  the  septum  from  a  branch  of  the  artery  to  the 
septum.  The  spot  should  be  touched  with  the  point  of  a 
fine  electric  cautery  or  a  small  piece  of  chromic  acid  on  a 
probe  may  be  rubbed  into  it.  If  the  bleeding  is  from  far- 
ther back  in  the  nose  and  it  is  impossible  to  locate  the 
spot,  the  head  should  be  raised  and  the  patient  kept  quiet 


154  SUEGEEY    OF    THE    BLOOD-VESSELS. 

with  an  ice  bag  placed  to  the  head  or  neck.  This  pro- 
duces a  reflex  contraction  of  the  smaller  arteries  and  will 
often  control  the  hemorrhage.  The  old-fashioned  prac- 
tice of  dropping  a  bunch  of  cold  keys  down  the  back  of 
the  neck  has  a  scientific  basis.  If  the  bleeding  still  per- 
sists, the  posterior  nares  should  be  packed.  This  can 
be  readily  done  by  passing  a  small  soft  rubber  catheter 
along  the  floor  of  the  nose  until  it  appears  in  the  pharynx. 
The  catheter  is  then  seized  with  forceps  through  the 
mouth  and  drawn  out.  A  mass  of  gauze  is  tied  to  its 
end  and  shoved  well  into  the  pharynx  and  up  into  the  pos- 
terior nares.  The  catheter  is  then  pulled  on,  which  main- 
tains the  tension.  In  profuse  bleeding  it  may  be  well  to 
attach  two  stout  cords  to  the  catheter  and  draw  them 
through  the  nose.  The  gauze  is  then  tied  on  the  cords, 
pulled  up  into  the  posterior  nares,  and  a  plug  of  gauze 
fitted  into  the  anterior  nares  and  held  in  position  by  ty- 
ing the  cords  together  over  it.  A  large  rubber  finger  cot 
or  a  small  rubber  glove  may  be  carried  on  a  probe  along 
the  floor  of  the  nares  and  inflated  to  produce  pressure. 
A  finger  cot  may  be  tied  over  the  end  of  the  catheter  if 
the  bleeding  area  can  be  reached  this  way,  inserted  oppo- 
site the  bleeding  spot,  and  then  blown  tense  through  the 
catheter.  Sometimes  the  nose  is  tamponed  with  strips 
of  gauze.  In  hemophiliacs,  when  the  blood  clots  slowly, 
tampons  are  very  unsatisfactory.  Various  solutions 
have  been  used  but  probably  the  best  is  the  application 
of  peroxide  of  hydrogen  by  means  of  an  atomizer,  re- 
peated at  frequent  intervals,  spraying  only  a  small 
amount  at  a  time.  It  is  said  to  be  a  most  efficient  means 
of  controlling  nasal  hemorrhage.  Suprarenal  extract  if 
strong  enough  to  control  the  bleeding,  may  be  danger- 
ous, partly  from  the  constitutional  effect,  but  largely  be- 
cause a  secondary  relaxation  often  sets  in,  the  vessels 


HEMORRHAGE.  155 


being  paralyzed  from  the  intense  contraction,  and  hl< 
ing  may  be  even  more  difficult  to  check  than  it  was  at 
first.  Sometimes  it  is  even  necessary  to  ligate  the  exter- 
nal carotids  in  the  neck. 

Bleeding  from  the  mouth  is  usually  serious  only  in 
cases  of  hemophilia,  though  in  an  angioma  of  the  mouth 
it  is  often  profuse.  If  there  is  a  persistent  oozing,  freez- 
ing the  tissues  with  ethyl-chloride  may  stop  it.  Too 
much  of  this  drug  should  not  be  used  as  it  is  a  very  strong- 
general  anesthetic,  and  the  surplus  should  be  caught  on 
gauze  packed  around  the  bleeding  surface.  Packing  the 
cavity  full  of  gauze  or,  in  an  emergency,  using  a  clean 
handkerchief,  and  having  the  patient  shut  his  mouth 
firmly  on  the  packing  will  control  most  hemorrhages 
along  the  alveolar  process,  even  if  very  severe. 

Hemorrhage  from  the  tongue  is  controlled  by  a  suture 
placed  through  the  tongue  just  posterior  to  the  bleeding 
surface,  or  the  bleeding  surface  if  small  may  be  sutured. 
Bleeding  from  the  tonsils  is  often  obstinate,  especially 
after  the  radical  operation  for  excision.  Washing  out 
the  throat  thoroughly  by  gargling  with  very  hot  water, 
or  with  ice  water,  and  pressure  on  the  bleeding  area 
with  dry  gauze  is  usually  sufficient  to  check  the  bleeding. 
Special  instruments  are  devised  by  which  continuous 
pressure  is  exerted  by  means  of  a  forceps  holding  gauze 
in  one  arm  which  is  inserted  into  the  throat,  the  other 
arm  being  placed  externally.  The  pressure  is  regulated 
by  a  catch  or  screw,  or  by  an  elastic  band.  If  bleeding 
is  not  checked  in  this  way  the  external  carotid  should  be 
ligated,  care  being  taken  to  include  the  ascending  phar- 
angeal,  which  comes  from  the  external  carotid  near  its 
origin. 

Bleeding  from  the  neck  requires  no  special  measures 
except  care  to  avoid  entrance  of  air  into  the  veins.  This 


156  SURGERY    OF    THE    BLOOD-VESSELS. 

is  peculiarly  liable  to  happen  in  the  internal  jugular  and 
the  large  veins  in  the  root  of  the  neck.  Arterial  hemor- 
rhage may  often  be  checked  by  posture,  elevating  the 
head  and  neck,  and  by  putting  a  tourniquet  on  the  arms 
and  legs  near  the  trunk  to  obstruct  the  venous  circula- 
tion, but  not  the  arterial — the  so-called  ''sequestration 
anemia"  mentioned  above.  The  patient  should  be  care- 
fully watched  to  prevent  the  blood  pressure  becoming  too 
low.  In  a  stab  of  the  neck  where  the  wound  is  small,  the 
finger  should  be  inserted  to  control  the  bleeding  spot.  If 
it  cannot  be  controlled  in  this  way,  gauze,  or  a  clean  hand- 
kerchief in  an  emergency,  is  packed  in  and  pressure 
maintained  until  the  wound  is  enlarged,  and  the  bleeding 
point  identified  and  properly  closed.  In  operations  on 
the  neck,  hemorrhage  should  be  carefully  controlled  by 
ligature  or  suture  before  the  wound  is  sutured,  as  the 
strain  of  vomiting  or  coughing  after  an  anesthetic  raises 
the  blood  pressure,  particularly  in  the  neck,  and  the  move- 
ments of  the  head  may  accelerate  bleeding. 

Hemorrhage  from  the  chest  if  superficial  is  treated 
on  the  general  principles  already  outlined.  Usually  the 
bleeding  point  can  be  clamped  and  ligated.  If  the  hem- 
orrhage is  from  the  heart,  the  heart  should  be  sutured 
according  to  the  methods  described  in  surgical  works  on 
this  subject.  Hemorrhage  from  the  intercostal  arteries 
is  often  severe.  The  lower  intercostal  artery  hugs  the 
rib  closely.  In  resection  of  the  rib,  if  the  periosteum  is 
stripped  off,  the  artery  will  not  be  injured.  In  com- 
pound fracture  of  the  rib,  the  hemorrhage  may  be  quickly 
controlled  by  passing  a  catgut  ligature  around  the  rib  a 
short  distance  from  its  end,  taking  care  to  include  con- 
siderable soft  tissue  in  the  suture.  This  can  be  tied 
firmlv  and  will  occlude  the  intercostal  vessels.  Bleeding 


HEMORRHAGE.  If)  7 

from  the  lung  is  controlled  by  packing  and  by  letting  air 
into  the  pleural  cavity  through  a  drainage  tube.  This 
causes  collapse  of  the  lung  and  consequent  contraction 
of  the  bleeding  spots.  The  great  danger  in  such  in- 
stances is  the  possibility  of  infection  of  the  pleural  cav- 
ity. 

In  the  abdomen,  the  chief  sources  of  hemorrhage  are 
the  stomach,  intestines,  kidneys,  bladder,  liver,  spleen, 
and  uterus.  The  liver  on  account  of  its  size  and  the 
spleen  on  account  of  its  structure  are  frequently  injured 
and  control  of  the  bleeding  may  be  difficult.  The  bleed- 
ing area  should  be  sutured  with  heavy  catgut  on  a  blunt 
needle  or  probe  and  the  sutures  tied  gently.  If  suturing 
is  impossible,  gauze  packing  should  be  used.  Hemor- 
rhage from  the  stomach  may  be  due  to  a  passive  hyper- 
emia  from  affections  of  the  liver  such  as  cirrhosis,  an 
ulcer,  a  tumor,  or  an  inflammatory  mass  which  presses 
upon  the  veins.  Affections  of  the  spleen,  such  as  spleno- 
megaly, which  produces  great  hyperemia  in  the  neighbor- 
hood of  the  spleen  and  in  the  liver,  also  cause  bleeding 
from  the  stomach.  Such  hemorrhages  are  treated  by 
emptying  the  stomach  and  often  by  gastric  lavage,  using 
hot  water  to  which  a  small  amount  of  soda  has  been 
added.  A  frequent  cause  of  hemorrhage  of  the  stomach 
is  gastric  or  duodenal  ulcer. 

Hemorrhage  from  gastric  ulcer  is  always  a  serious 
matter.  The  authorities  estimate  that  from  three  to  six 
percent  of  all  patients  having  gastric  or  duodenal  ulcer 
die  from  hemorrhage.  Thus,  von  Mikulicz  l  says  that  in 
gastric  ulcer  "Leube  observed  hemorrhage  in  forty-six 
percent  of  his  cases.  Miiller  says  it  was  present  in  120 
cases  which  came  to  autopsy,  it  being  the  cause  of  death 

1  Von   Bergmann    and   Bull:    System  of   Practical    Surgery,   Vol.    IV,   page   304. 


158  SURGERY    OF    THE    BLOOD-VESSELS. 

in  fourteen  of  these  cases.  Welch  estimates  that  from 
three  to  five  percent  of  patients  having  gastric  ulcer  die 
from  hemorrhage." 

Thompson,  professor  of  surgery  in  the  University  of 
Texas,  describes  two  cases  of  duodenal  ulcer  in  his  own 
practice  that  died  from  hemorrhage.-  In  referring  to 
the  literature  he  says  Moynihan  reports  that  "in  his  sec- 
ond series  of  cases  (101)  hemorrhage  occurred  in  forty- 
nine  (almost  fifty  percent)."  He  also  says,  "Perry  and 
Shaw  estimated  that  thirteen  percent  of  the  bleeding 
cases  end  fatally."  Moynihan3  divides  these  cases  into 
four  classes.  In  the  first,  the  hemorrhage  is  trivial  and 
often  inconspicuous.  In  the  second,  it  is  somewhat  more 
severe.  In  the  third  group,  the  hemorrhage  occurs  after 
an  exacerbation  of  other  symptoms.  In  chronic  cases  it 
is  repeated  and  abundant.  "Its  persistence  and  excess 
cause  grave  peril  and  will,  if  unchecked,  be  the  deter- 
mining cause  of  the  patient's  death."  In  the  fourth 
group  the  hemorrhage  is  overwhelming  and  lethal.  Ob- 
servable hemorrhage  occurs  in  about  fifty  percent  of  all 
cases  of  gastric  or  duodenal  ulcer  and  about  one-tenth 
of  these  die  solely  from  hemorrhage. 

The  treatment  of  this  complication,  then,  is  of  great 
importance.  In  acute  cases,  the  hemorrhage  will  usually 
stop  under  medical  treatment,  and  it  is  important  to 
recognize  acute  cases.  They  occur,  as  a  rule,  in  young 
adults  and  are  preceded  by  symptoms  for  only  a  few 
days  or  a  few  weeks  at  most.  The  chief  symptom  is 
pain,  referred  to  a  point  between  the  ensiform  cartilage 
and  the  navel.  If  the  stomach  is  emptied  and  kept  at 
rest  for  several  weeks,  acute  cases  usually  do  not  suffer 
from  recurrent  hemorrhage.  The  chronic  cases  may  oc- 

2  Transactions    of    Southern    Surgical    and    Gynecological    Association,    Vol.    XXV. 
page  249. 

3  Abdominal  Operations,   page   160. 


HEMORRHAGE.  1")1) 

cur  either  in  young  adults,  or  in  the  middle  aged  or  old. 
They  have  a  history  of  indigestion  for  months  or  years, 
and  suffer  from  "nervous  dyspepsia"  relieved  sometimes 
by  soda  or  food.  Here  hemorrhage  is  most  dangerous. 
It  is  this  type  that  belongs  to  the  third  and  fourth  groups 
of  Moynihan. 

The  treatment  consists  in  giving  the  stomach  absolute 
rest  by  withholding  both  food  and  water  and  in  nourish- 
ing the  patient  per  rectum.  Duodenal  feeding  through 
a  small  tube  may  be  practiced  after  the  acute  danger  of 
hemorrhage  is  over  and  when  the  rectum  begins  to  be  in- 
tolerant. The  principles  of  treatment  are  the  same  as 
in  incomplete  abortion.  The  uterus  is  emptied  in  the 
latter  instance  to  permit  the  contraction  of  its  walls,  thus 
closing  the  vessels.  Keeping  the  stomach  empty  does 
the  same  thing.  If  bleeding  persists  or  recurs,  particu- 
larly in  chronic  cases,  operation  should  be  done.  The 
pylorus  should  be  folded  in  on  itself  with  sutures  and  a 
posterior  gastro-enterostomy  by  the  no-loop  method  per- 
formed. The  folding  in  of  the  pylorus  usually  produces 
some  pressure  upon  the  ulcer  and  the  gastro-enteros- 
tomy drains  the  stomach  and  keeps  it  collapsed.  If  the 
hemorrhage  is  large  in  quantity,  persistent,  and  recur- 
rent, particularly  in  the  middle  aged,  and  if  the  patient 
seems  too  anemic  to  stand  an  immediate  operation,  trans- 
fusion of  blood  should  be  done,  followed  immediately 
by  gastro-enterostomy  and  closure  of  the  pylorus.  Here 
transfusion  renders  operation  comparatively  safe. 
With  the  waiting  method  in  such  cases,  as  shown  by  the 
authorities  quoted,  death  will  often  occur  from  hemor- 
rhage or  the  resulting  anemia  may  produce  nervous  and 
mental  symptoms,  as  has  been  pointed  out  by  Crile. 

Hemorrhage  from  the  bowel  except  from  the  rectum 
is  difficult  to  control  by  direct  applications.  Bleeding 


160  SUEGERY    OF    THE    BLOOD-VESSELS. 

from  typhoid  ulcers  if  severe  may  possibly  be  subjected 
to  operation,  though  only  after  other  means  of  checking 
the  hemorrhage  have  been  tried.  Prophylaxis  in  regard 
to  the  diet  and  rest  of  the  intestinal  tract  should  always 
be  observed.  If,  however,  the  hemorrhage  is  persistent 
a  laparotomy  under  local  anesthesia  would  be  justifiable. 
The  hemorrhage  probably  comes  from  the  lower  two  feet 
of  the  ileum,  which  is  also  a  frequent  site  of  perforation. 
The  bleeding  spot  is  controlled  by  excision  of  the  ulcer 
and  suturing  the  wound  carefully  with  two  layers  of  su- 
tures. If  well  localized  and  small,  it  may  be  infolded 
with  a  purse-string  suture,  but  with  skilful  suturing 
excision  of  the  ulcer  will  probably  be  more  satisfactory 
than  attempting  to  infold  a  mass  of  diseased  and  thick- 
ened intestine.  If  the  suturing  is  gently  done  under 
novocaine  without  too  much  pulling  on  the  intestine  or 
its  mesentery,  there  will  be  surprisingly  little  shock, 
though  any  operation  is  a  serious  matter  in  the  usually 
desperate  condition  of  these  patients. 

Hemorrhage  from  the  rectum  should  be  controlled  if 
possible  by  direct  suture  of  the  bleeding  point,  though 
if  bleeding  is  chiefly  venous,  a  tube  wrapped  with  gauze 
and  inserted  in  the  rectum  through  a  speculum  will 
stop  the  hemorrhage.  There  should  be  enough  gauze  to 
produce  considerable  pressure;  the  tube  allows  the  es- 
cape of  gas.  Hemorrhages  from  the  liver  from  acciden- 
tal wounds  are  controlled  by  sutures,  which  may  be  ap- 
plied with  special  blunt  needles,  called  liver  needles,  or 
by  means  of  a  probe  which  is  easily  passed  through  the 
liver  tissue,  or  by  passing  a  large  needle  eye  first, 
The  stitches  are  tied  carefully  because  if  too  much  ten- 
sion is  made  they  will  cut  through.  Very  stout  catgut 
is  the  best  material,  and  the  stitches  may  be  placed  in- 
terruptedly or  as  a  continuous  mattress  or  a  cobbler's 


HEMORRHAGE.  K)l 

stitch.  If  a  portion  of  the  liver  is  resected,  its  raw  sur- 
faces should  be  brought  together  with  sutures,  which 
readily  controls  the  bleeding. 

Hemorrhage  from  the  kidneys  is  sometimes  exceed- 
ingly troublesome.  It  is  often  more  indicative  of  a  seri- 
ous affection  of  the  kidney  than  dangerous  in  itself. 
Malignant  growths  frequently  bleed  in  the  early  stages. 
The  so-called  essential  hemorrhage  of  the  kidney,  which 
is  supposed  to  occur  without  organic  lesion,  is  rapidly 
disappearing  on  finding,  as  a  rule,  organic  lesions  as  a 
cause  of  most  hemorrhages.  Renal  hemorrhage  is  usu- 
ally caused  by  stone,  malignant  growths,  tuberculosis,  or 
nephritis,  but  there  still  remains  a  small  group  of  so- 
called  essential  hemorrhages  difficult  to  explain.  In  a 
few  cases  it  is  probable  that  enlarged  veins  about  the 
calices  are  the  source  of  the  bleeding.  Internal  remedies 
are  of  doubtful  advantage.  H.  H.  Young  has  recom- 
mended catheterizing  the  ureters  and  irrigating  the  pel- 
vis of  the  kidney  with  a  weak  solution  of  suprarenal  ex- 
tract. Internal  administration  of  tincture  of  guaiac  has 
been  recommended,  though  its  action,  if  it  has  any,  ap- 
pears to  be  empirical.  Often  incision  through  the  cap- 
sule of  the  kidney,  stripping  the  capsule,  or  an  incision 
into  the  pelvis  of  the  kidney  seems  to  stop  the  bleeding. 
It  is  supposed  that  by  this  latter  procedure  dilated  veins 
are  broken  and  destroyed.  Sometimes  the  hemorrhage 
demands  a  nephrectomy.  Bleeding  from  injuries  of  the 
kidney  is  controlled  by  firm  packing  or  by  suture.  Su- 
ture is  by  all  means  preferable  when  it  can  be  used. 
Catgut  is  the  best  suture  material  and  is  inserted  in 
round  needles.  The  stitch  should  be  interrupted  and 
just  tight  enough  to  check  the  bleeding,  for  if  too  tight 
it  will  certainly  cut  through.  Even  profuse  bleed- 
ing from  the  kidney  is  readily  controlled  by  a  few  su- 


1G2  SURGERY    OF    THE    BLOOD-VESSELS. 

tures  tied  gently.  The  mattress  stitch,  advocated  by 
some,  stops  bleeding  but  injures  a  great  deal  of  the  kid- 
ney parenchyma,  as  all  of  the  kidney  substance  within 
its  grasp  may  be  destroyed;  whereas  with  a  simple  inter- 
rupted suture,  the  only  tissue  affected  is  in  the  direct 
plan  of  the  stitch.  Several  experimenters  have  shown 
the  advantage  of  the  simple  stitch  in  this  connection, 
some  of  the  best  work  along  this  line  being  done  by  James 
E.  Moore  and  J.  Frank  Corbett,  of  Minneapolis. 

Hemorrhage  arising  from  the  bladder  is  infrequent, 
for  usually  blood  in  the  urine  is  from  the  kidneys  or 
urethra.  However,  tumors  of  the  bladder,  particularly 
papillomas,  or  growths  of  the  prostate  may  cause  severe 
bleeding.  AVhen  the  prostate  is  enlarged  and  its  veins 
engorged,  the  hemorrhage  is  often  difficult  to  control  un- 
less the  prostate  itself  which  causes  the  engorgement  is 
removed.  Irrigating  the  bladder  with  hot  water  is  one 
of  the  most  satisfactory  methods  of  checking  bleeding 
from  the  bladder.  In  persistent  hemorrhage  from  a  pap- 
illoma,  the  growth  itself  should  be  removed  either  by 
operation  or  by  electricity,  using  either  the  high  fre- 
quency, or  dessication,  or  the  d'Arsonval  current  which 
is  highly  recommended  for  neoplasms  of  the  bladder, 
even  for  malignant  growths. 

After  wounds  of  the  bladder,  particularly  after  pros- 
tatectomy, control  of  hemorrhage  is  exceedingly  impor- 
tant as  the  elderly  patients  on  whom  prostatectomy  is 
done  bear  loss  of  blood  poorly.  Bleeding  can  be  con- 
trolled 'after  a  suprapubic  operation  better  than  after  the 
perineal  method,  for  if  packing  is  used  it  can  be  firmly 
pressed  down  on  the  wound,  or  if  irrigation  is  relied 
upon  the  bladder  can  be  kept  full  of  hot  fluid.  In  the 
perineal  method  the  water  must  either  return  immedi- 
ately through  a  larger  tube  or  else  must  accumulate 


HEMOERHAGE.  IG.'J 

under  pressure,  while  packing  frequently  forces  its  way 
into  the  bladder  and  is  not  efficient.  After  the  supra- 
pubic  operation  several  measures  are  advocated.  Some 
surgeons,  as  Cabot,  of  Boston,  make  a  wide  incision 
into  the  bladder  and  suture  the  bleeding  cavity  with  a 
continuous  catgut  stitch,  paying  particular  attention 
to  the  posterior  margin  of  the  wound  where  it  is  claimed 
the  arterial  bleeding  occurs.  Others  advocate  firm 
packing  of  the  cavity  which  is  retained  either  by  a 
catgut  stitch  or  by  leaving  a  pair  of  forceps  to  press  upon 
the  packing,  having  the  handles  of  the  forceps  protrude 
from  the  wound  and  attached  to  a  light  elastic  band 
across  the  dressing.  Or  the  packing  may  be  attached  to 
a  rubber  catheter  which  has  been  introduced  through  the 
urethra  and  traction  made  on  the  catheter.  If  packing 
is  left  without  some  retentive  apparatus,  it  does  not  re- 
main in  the  cavity  from  which  the  prostate  is  removed 
and  it  may  be  necessary  to  fill  the  bladder  with  gauze. 
Packing  is  often  accompanied  by  reflex  disturbance  of 
the  kidneys,  and  tends  to  promote  uremia.  If  the  gauze 
is  left  in  for  several  days,  its  removal  is  painful  and 
may  be  followed  by  secondary  hemorrhage,  as  occurred 
in  one  of  the  author's  cases. 

Personally,  the  author  uses  the  following  method  for 
controlling  bleeding  after  prostatectomy.  The  prostate 
is  removed  by  the  suprapubic  method  of  Squier.  With 
the  finger  in  the  rectum,  the  wound  is  elevated  and  then 
packed  for  a  few  minutes  with  dry  gauze.  The  packing 
is  removed  and  if  any  particular  bleeding  spot  can  be 
readily  caught  with  forceps,  this  is  done  and  the  point 
ligated,  but  no  time  is  wasted  in  making  a  search  for 
bleeding  points  unless  they  are  quite  obvious.  A  large 
tube  is  placed  in  the  bladder  at  the  upper  angle  of  the 
wound  and  fastened  with  a  suture,  and  a  very  small 


164  SUKGEEY   OF   THE   BLOOD-VESSELS. 

rubber  catheter  is  passed  through  the  urethra.  The 
packing  is  removed  and  hot  water  is  turned  on  through 
the  catheter.  The  temperature  at  first  is  about  120°F. 
The  large  tube  does  not  reach  to  the  bottom  of  the  wound. 
In  this  way  a  constant  head  of  hot  water  is  kept  stand- 
ing in  the  bladder.  The  bladder  is  sewed  up  while  the 
solution  is  running,  and  care  should  be  taken  to  remove 
all  clots  before  the  bladder  is  completely  closed.  If  this 
is  done  and  the  solution  is  constantly  running,  the  blood 
will  be  so  diluted  and  carried  off  that  it  will  not  have 
time  to  clot.  The  interruption  of  the  flow  for  even  a  few 
minutes  for  the  first  few  hours  after  operation  permits 
clotting  and  plugging  of  the  tube.  The  tube  is  fastened 
securely  in  position  by  suturing  it  to  the  skin  and  is 
brought  out  from  the  upper  angle  of  the  bladder  wound. 
A  chromic  or  tanned  catgut  mattress  stitch  is  put  through 
the  bladder  around  the  tube  and  left  long  with  the  ends 
untied.  Hot  water,  which  may  be  semi-saturated  with 
boric  acid,  should  be  kept  constantly  flowing  through  the 
catheter  though  plain  hot  water  that  has  been  boiled  is 
all  that  is  necessary.  Overflow  is  prevented  by  having 
the  large  tube  connected  with  an  apparatus  that  consists 
of  a  small  tin  cylinder  screwed  on  the  top  of  a  quart 
Mason  preserve  jar.  There  are  two  tubes  in  the  top  and 
one  considerably  larger  about  the  middle  of  the  side  of 
the  cylinder.  This  latter  tube  is  slightly  bent  so  as  to 
form  a  syphon.  The  smaller  tube  in  the  top  of  the  tin 
cylinder  is  connected  with  a  faucet  or  with  a  jar  contain- 
ing water.  The  larger  of  the  two  tubes  on  top  drains 
the  bladder.  The  apparatus  is  screwed  tightly  to  the  jar 
which  sits  on  a  stool  by  the  patient's  bed  at  a  lower  level 
than  the  bed.  It  empties  through  the  syphon  into  a  slop 
jar  or  a  large  foot  basin  or  tub.  The  flow  of  the  water 
through  the  smaller  tube  on  top  fills  the  tin  cylinder  up 


HEMOERHAGE. 


105 


to  the  top  level  of  the  exit  tube.  This  exit  tube  then 
overflows  and,  acting  as  a  syphon,  sucks  up  the  water 
and  diluted  blood  and  urine  from  the  bladder  by  creat- 
ing negative  pressure.  The  flow  into  the  bladder  should 
be  small.  Hot  water  is  kept  constantly  in  the  bladder 
up  to  the  level  of  the  lower  end  of  the  large  drainage 
tube.  The  suction  may  be  made  faster  or  slower  accord- 
ing to  the  amount  of  water  running  into  the  apparatus 
from  the  smaller  top  tube.  The  advantages  of  this  ap- 
paratus are  that  it  keeps  the  patient  dry,  a  head  of  hot 
water  is  constantly  in  the  bladder,  and  the  flow  can  be 
regulated  at  will. 

Hemorrhage  from  the  urethra,  and  particularly  from 
the  deep  urethra,  is  sometimes  severe.  When  the  for- 
mer practice  of  cutting  deep  strictures  with  a  urethra- 
tome  was  in  vogue,  such  hemorrhages  were  common. 
They  may  be  controlled  by  the  passage  of  a  large  sound 
or  by  a  catheter  over  which  a  finger  cot  has  been  tied, 
the  finger  cot  being  inflated  through  the  catheter  when  in 
place,  as  has  been  mentioned  under  the  head  of  nasal 
bleeding.  If  these  methods  are  not  effective,  an  external 
urethrotomy  should  be  done,  a  large  tube  introduced  into 
the  bladder  and  iodoform  gauze  packed  around  the  tube. 
The  bleeding  may  be  controlled  by  catgut  sutures  if  the 
bleeding  points  are  accessible. 

Hemorrhage  from  the  uterus  is  due  to  the  results  of 
pregnancy  or  trauma,  to  a  tumor,  or  to  disease  of  the 
uterine  tissues.  When  bleeding  is  from  an  incomplete 
abortion,  the  indication  is  to  clean  out  the  uterus,  so  per- 
mitting it  to  contract  and  close  the  vessels.  If  much 
blood  has  been  lost  and  the  patient  is  weak,  the  uterus 
sometimes  does  not  contract  and  should  be  packed  firmly 
with  gauze,  preferably  with  washed  iodoform  gauze.  In 
hemorrhage  from  placenta  previa,  the  usual  obstetrical 


166  SURGERY    OF    THE    BLOOD-VESSELS. 

rules  are  followed  and  an  effort  is  made  to  bring  down 
the  presenting  part  of  the  child  and  plug  the  cervix.  If 
the  hemorrhage  is  severe,  or  if  the  life  of  the  child  is 
in  danger,  a  rapid  extraction  should  be  made.  Cresa- 
rean  section  is  advised  for  cases  in  which  delivery  by 
the  natural  route  would  prove  difficult  or  tedious.  Tears 
of  the  cervix  sometimes  cause  severe  bleeding  which  is 
controlled  by  sutures.  Tanned  catgut,  silk,  or  silkworm 
gut  may  be  used;  plain  catgut  is  absorbed  very  rapidly 
in  this  location.  Sometimes  secondary  hemorrhage  oc- 
curs after  operations  for  tears  of  the  cervix  or  for  am- 
putation of  the  cervix  as  late  as  the  tenth  day  and  even 
when  the  bleeding  at  the  time  of  operation  was  insignifi- 
cant. Such  hemorrhages  are  difficult  to  explain,  but  are 
said  by  some  to  be  due  to  a  mild  infection.  They  are 
more  frequent  after  the  use  of  plain  or  chromic  catgut. 
If  hot  douches  and  packs  do  not  readily  control  the  sec- 
ondary bleeding,  the  cervix  is  sutured  with  silkworm  gut 
which  can  be  removed  after  two  or  three  weeks ;  it  would 
be  unwise  to  try  catgut  a  second  time.  Bleeding  from  a 
benign  tumor,  such  as  a  submucous  fibroid,  is  often  due 
to  the  fact  that  the  tumor  acts  as  a  splint  and  prevents 
the  uterus  from  contracting  on  the  blood-vessels.  If  such 
a  tumor  is  removed  the  hemorrhage  stops.  A  submucous 
fibroid  is  often  extruded  through  the  cervix.  Bleeding 
from  cancer  should,  of  course,  be  controlled  by  a  radical 
hysterectomy  if  the  disease  admits  of  such  an  operation. 
If  not,  thorough  curetting,  followed  by  an  application  of 
the  actual  cautery,  or  the  Percy  cautery,  will  usually 
check  the  hemorrhage.  There  is  a  form  of  endometritis, 
accompanied  by  some  change  in  the  blood-vessels  of  the 
uterus,  which  is  particularly  liable  to  bleed.4  While  these 

4Cullen:    Surgery,    Gynecology   &   Obstetrics,   October,    1913. 


HEMOREHAGE.  LtH 

cases  are  often  cured  after  one  or  two  curettements,  some- 
times the  bleeding  recurs  in  a  few  months  and  demands 
hysterectomy.  In  one  of  the  author's  cases  after  thor- 
ough curetting  on  two  previous  occasions,  the  patient  be- 
came exceedingly  anemic  from  the  bleeding,  which  again 
recurred,  hemoglobin  falling  to  twenty.  After  transfu- 
sion, hysterectomy  was  done  and  the  patient  made  a 
prompt  recovery.  Radium,  applied  to  the  uterine  cav- 
ity, is  said  to  be  very  effective  in  controlling  chronic 
bleeding  from  the  uterus.  The  application  of  heat  by 
water  or  steam  has  already  been  referred  to. 

After  chronic  uterine  hemorrhage,  not  infrequently 
the  patients  become  accommodated  to  a  low  hemoglobin, 
as  has  been  pointed  out  by  Byford,  and  the  tissues  by 
some  form  of  compensation  seem  sufficiently  nourished. 
However,  in  this  condition  the  patient's  resistance  is  low 
and  she  will  easily  succumb  to  a  disease  that  she  could 
normally  resist. 

Hemorrhage  from  the  extremities  where  a  tourniquet 
can  be  applied,  may  be  dealt  with  on  general  principles. 
If  a  tourniquet  is  used,  it  should  not  be  permitted  to  re- 
main longer  than  an  hour  and  a  half,  and  it  should  be 
tight  enough  to  constrict  absolutely  the  arteries.  It  is 
applied  preferably  on  the  thigh  or  arm.  No  motion  of 
the  limb  should  be  permitted  when  the  tourniquet  is  on 
for  fear  of  rupturing  the  muscle.  An  emergency  tourni- 
quet can  be  made  either  of  elastic  material,  such  as  sus- 
penders, or  of  a  handkerchief  or  towel.  This  may  be 
tied  tightly  and  a  long  pencil  or  rod  slipped  underneath 
and  twisted  in  such  a  way  as  to  tighten  the  towel  or  hand- 
kerchief. Thus,  any  reasonable  amount  of  pressure  can 
be  exerted.  If  the  hemorrhage  is  not  profuse,  packing 
with  gauze  together  with  elevation  of  the  limb  and  the 


168  SURGERY    OF    THE    BLOOD-VESSELS. 

application  of  a  bandage  over  the  dressing  is  usually  suf- 
ficient. According  to  recent  views  of  military  surgeons 
packing  should  not  be  used  in  the  wound  as  it  predisposes 
to  infection,  but  a  gauze  dressing  and  a  firm  bandage 
should  be  applied.  If  profuse  and  arterial,  the  finger 
should  be  applied  to  the  bleeding  spot  until  the  wound 
can  be  enlarged  and  the  vessel  secured. 


CHAPTER  IX. 
PATHOLOGIC  HEMORRHAGE. 

Pathological  hemorrhage  is  due  to  some  change  in  the 
blood,  or  in  the  ultimate  capillaries.  There  may  be  a 
slight  trauma  or  the  hemorrhage  may  occur  without 
trauma  as  frequently  happens  in  purpura.  The  diseases 
in  which  pathologic  hemorrhage  most  frequently  occurs 
are  hemophilia,  chronic  jaundice,  purpura,  and  melena 
neonatorum.  Purpura  is  really  a  symptom  rather  than 
a  disease  and  may  occur  with  hemophilia.  It  implies 
subcutaneous  and  submucous  hemorrhages.  The  cause 
of  melena  neonatorum  is  not  definitely  known,  but  it 
seems  probable  that  it  is  not  due  to  a  disease  of  the 
blood-vessels  themselves  or  to  an  infection,  but  is  a  con- 
genital malformation  of  the  blood,  the  exact  nature  of 
which  is  unknown.  In  all  of  these  diseases  it  is  likely 
that  there  is  some  defect  in  the  formation  of  fibrin  fer- 
ment. Adis  concludes  that  hemophilia  is  due  to  an  in- 
herited defect  in  thrombogen  (prothrombin)  whereby  it 
is  less  readily  activated  than  normal  thrombogen  would 
be.  Sahli  thinks  the  lack  of  coagulability  is  due  to  a  de- 
ficiency of  thrombokinase  and  that  this  in  turn  comes 
from  some  defect  both  in  the  blood  corpuscles  and  in  the 
endothelial  cells.  It  is  well  known  that  hemophilic  blood 
coagulates  promptly  on  the  addition  of  fibrin  ferment, 
so  that  some  process  involving  the  formation  of  fibrin 
ferment  is  defective.  Normal  thrombus  formation  has 
already  been  mentioned,  and  the  thrombokinase,  which 
is  supposed  to  be  universal  in  the  body  and  which  acts 

169 


170  SURGERY    OF    THE    BLOOD-VESSELS. 

upon  thrombogen  to  form  fibrin  ferment  in  the  presence 
of  calcium  salts,  may  be  at  fault  in  hemophilia. 

Some  observers  have  noticed  that  the  clotting  of  blood 
from  a  hemophiliac  is  not  materially  altered  if  taken 
from  an  old  wound,  but  when  blood  from  a  fresh  wound 
is  allowed  to  drop  into  a  test  tube,  the  corpuscles  soon 
fall  to  the  bottom  and  sometimes  clotting  does  not  occur 
for  several  hours.  Hemophilia  is  a  hereditary  disease 
and  usually  occurs  in  males,  though  the  tendency  toward 
this  disease  may  be  transmitted  by  females.  The  ratio 
has  been  given  variously  as  from  four  males  to  one  fe- 
male up  to  as  high  as  thirteen  males  to  one  female.  Os- 
ier mentions  families  that  have  been  noted  as  hemophili- 
acs for  a  number  of  generations. 

In  the  study  of  the  blood  of  the  hemophiliac,  nothing 
definite  has  been  found.  It  is  supposed  that  the  blood 
platelets  are  usually  diminished  in  number.  In  two 
cases  of  hemophilia  Cabot  found  white  blood  corpuscles 
and  red  corpuscles  both  considerably  reduced.  Wright 
has  found  a  small  number  of  white  corpuscles  with  a  de- 
ficiency in  the  percentage  of  polynuclears,  while  others 
have  found  a  leukocytosis.  The  one  constant  feature 
seems  to  be  a  small  number  of  the  platelets. 

In  most  instances,  the  bleeding  of  a  hemophiliac  comes 
from  some  slight  injury.  The  majority  of  cases  re- 
ported are  from  the  nose,  or  from  some  part  of  the 
mouth.  Hemorrhage  also  comes  from  the  intestinal 
tract,  urethra,  stomach,  or  from  any  part  of  the  body. 
The  slightest  trauma,  such  as  pulling  a  tooth,  a  scratch 
from  a  cat,  or  even  mosquito  bites  may  cause  a  continu- 
ous and  almost  uncontrollable  hemorrhage.  Sometimes 
purple  spots  from  subcutaneous  hemorrhage  appear  be- 
neath the  skin  or  mucous  membrane.  Often  the  joints 
are  painful  and  enlarged,  the  knee  and  elbow  being  fre- 


PATHOLOGIC    HEMORRHAGE.  171 

quently  affected.  This  is  due  to  hemorrhage  into  the 
joint.  Operations  upon  such  joints  are  always  exceed- 
ingly dangerous. 

Treatment  of  hemophilia  consists  in  the  administra- 
tion of  certain  drugs,  in  local  compression,  and  in  serum 
therapy.  If  the  bleeding  is  from  a  small  place  some- 
times the  application  of  cold  is  useful.  When  it  is  nec- 
essary to  extract  a  tooth  in  a  person  who  is  suspected 
of  being  a  hemophiliac,  it  is  well  first  to  freeze  the  gums 
with  ethyl-chloride.  The  local  application  of  suprarenal 
extract  has  been  advised  and  may  be  of  some  service. 
Unfortunately,  while  contracting  the  vessels  greatly  at 
the  time  of  application,  it  causes  a  secondary  paralysis 
as  a  result  of  this  intense  contraction,  and  may  eventu- 
ally make  the  hemorrhage  worse.  The  internal  admin- 
istration of  calcium  in  some  form  has  been  advised.  It 
may  be  given  per  rectum  as  chloride  of  calcium,  twenty 
grains  three  times  a  day,  or  by  mouth  or  rectum  as  lac- 
tate  of  calcium  in  similar  doses.  The  administration  of 
a  large  dose  of  calcium  or  giving  it  too  frequently,  some- 
times seems  to  have  the  opposite  effect  and  will  de- 
lay coagulation  instead  of  increasing  it.  The  local  ap- 
plication of  gauze  soaked  in  a  one  or  two  percent 
solution  of  calcium  chloride  has  been  advised.  The  ap- 
plication of  heat,  particularly  in  the  form  of  hot  water, 
occasionally  checks  the  bleeding. 

Among  the  general  measures  of  treatment  of  hemo- 
philia, are  regulation  of  the  diet,  proper  personal  hy- 
giene, and  fresh  air.  A  nutritious  diet  including  an 
abundance  of  milk  is  exceedingly  important.  Milk  is 
supposed  to  have  a  double  value  on  account  of  the  cal- 
cium lactate  it  contains.  The  internal  administration  of 
thyroid  extract,  grains  three,  three  or  four  times  a  day, 
has  been  followed  by  beneficial  results.  In  one  reported 


172  SURGERY    OF    THE    BLOOD-VESSELS. 

case  ovarian  extract  proved  successful  after  other  reme- 
dies had  failed.  Serum  therapy  should  he  used  in  addi- 
tion to  local  treatment,  if  the  hemorrhage  is  not  soon 
controlled.  This  is  really  the  most  logical  method  of 
treatment,  as  it  is  generally  agreed  that  the  cause  of  the 
hemorrhage  is  some  defect  in  the  fibrin  ferment.  For- 
eign serums  have  been  used.  Of  these  the  most  valuable 
is  the  serum  of  the  rabbit  or  the  horse.  From  ten  to 
twenty  cubic  centimeters  may  be  injected  into  the  veins 
or  subcutaneously.  Serum  from  a  human  being  is  best, 
though  that  from  a  horse  or  rabbit  may  be  used  with  good 
effect.  Sometimes  the  antitoxin  of  diphtheria  will  af- 
ford a  satisfactory  serum.  The  serum  from  cattle  or 
dogs  is  peculiarly  toxic  to  man  and  should  not  be  em- 
ployed under  any  condition.  Any  serum  soon  loses  its 
power  to  cause  coagulation  and  consequently  should  al- 
ways be  employed  fresh. 

The  active  principles  of  the  serum  obtained  from 
horses  seem  to  produce  satisfactory  results  and  to  exert 
no  deleterious  effect.  The  dried  serum  from  a  horse 
which  will  keep  indefinitely  under  proper  conditions  has 
been  put  upon  the  market  under  the  trade-name  of  ' '  Co- 
agulose."  It  seems  to  have  some  advantages  over  the 
administration  of  the  crude  serum. 

If  hemorrhage  has  been  going  on  for  some  time  and 
the  patient's  hemoglobin  is  reduced  to  the  neighborhood 
of  twenty,  transfusion  of  blood  is  indicated,  not  only 
because  of  the  benefit  of  the  serum  therapy  but  because 
transfusion  supplies  red  corpuscles.  Many  cases  have 
been  successfully  treated  by  transfusion  that  did  not  re- 
spond to  other  treatment.  Sometimes  transfusion  is  not 
successful,  but  as  it  is  used  only  after  other  remedies 
fail,  even  a  small  percentage  of  cures  is  gratifying. 

The  donor  in  transfusion  for  hemophilia  should  not 


PATHOLOGIC    HEMORRHAGE. 

be  a  blood  relative.  It  is  likely  that  a  blood  relative, 
particularly  if  close,  may  liave  the  same  kind  of  defect 
in  the  formation  of  fibrin  that  the  patient  has.  The  fol- 
lowing case,  which  is  reported  in  detail,  is  interesting 
partly  from  this  fact. 

The  patient,  a  man  about  forty-five  years  of  age,  was 
admitted  to  the  University  of  Minnesota  Hospital  in  the 
service  of  Dr.  A.  A.  Law,  and  operated  upon  for  appen- 
dicitis by  Dr.  Law's  assistant  on  June  18,  19.13.  Two 
days  later  there  was  bleeding  from  the  wound,  bladder, 
and  bowels.  He  was  given  forty  cubic  centimeters  of 
normal  serum  in  divided  doses  and  also  calcium  lactate, 
but  with  no  benefit.  At  the  courteous  invitation  of  Dr. 
Law  the  author  transfused  the  patient  on  June  '21.  His 
condition  at  that  time  was  very  bad,  pulse  weak  and 
running,  hemoglobin  twenty-eight,  and  he  was  still  bleed- 
ing. The  coagulation  time  of  his  blood  was  an  hour 
and  a  half.  The  patient's  son,  a  robust  young  man, 
was  the  donor.  The  patient  seemed  much  benefited, 
though  the  coagulation  time  was  not  greatly  decreased. 
The  following  day  his  hemoglobin  was  thirty-eight — an 
increase  of  more  than  one-third — and  his  coagulation 
time  was  seventy-five  minutes,  a  decrease  of  fifteen  min- 
utes, and  he  was  still  bleeding.  On  June  23,  two  days 
after  the  transfusion,  hemoglobin  had  dropped  to  twenty 
and  the  patient  was  practically  in  a  dying  condition. 
His  blood  did  not  coagulate  in  an  hour  and  a  half  and  he 
continued  to  bleed.  Dr.  Law  did  a  transfusion  with  the 
patient's  wife  as  donor.  He  used  a  cannula  and  there 
was  a  strong  flow  of  blood  for  fourteen  minutes.  The 
patient  was  greatly  improved,  the  coagulation  time  com- 
ing down  to  four  and  a  half  minutes  after  the  transfu- 
sion, as  against  more  than  an  hour  and  a  half  before,  and 
the  hemoglobin  increasing  to  thirty-eight.  The  im- 


174  SURGERY    OF    THE    BLOOD-VESSELS. 

provement  continued  and  011  July  26,  hemoglobin  was 
fifty-six  and  coagulation  time  seven  and  a  half  minutes. 
He  then  developed  some  bowel  disturbance  and,  on  Au- 
gust 1,  there  was  bleeding  from  the  gums  and  coagula- 
tion time  was  one  hour.  Thirty  cubic  centimeters  of 
whole  blood  were  injected  subcutaneously  and  the  bleed- 
ing stopped.  On  August  5,  the  pulse  became  bad,  there 
were  sighing  respiration,  extreme  pallor,  and  tarry  stools. 
Dr.  Law  did  another  transfusion,  but  the  patient  died 
within  three  minutes  after  the  blood  was  turned  on. 
He  was  really  dying  when  the  transfusion  was  begun. 
Autopsy  showed  nothing  of  significance  except  pulmo- 
nary edema  and  a  number  of  small  hemorrhages  in  the 
mucous  membrane  of  the  ileum.  The  most  interesting 
feature  of  this  case  is  the  marked  difference  in  the 
effect  of  the  blood  from  the  patient's  son  and  from 
his  wife.  The  former  probably  had  the  same  defect 
in  his  blood  as  the  patient,  but  to  a  limited  extent. 
Though  hemoglobin  was  increased  more  than  a  third  by 
the  transfusion,  the  coagulation  time  was  only  slightly 
decreased  and  the  bleeding  was  not  stopped.  However, 
with  the  alien  blood  of  his  wife  the  coagulation  time  was 
brought  down  from  more  than  an  hour  and  a  half  to  four 
and  a  half  minutes  and  the  bleeding  was  checked  at  once. 
The  course  of  this  case  suggests  strongly  a  deficiency 
in  fibrin  ferment,  possibly  in  the  thrombokinase  element ; 
and  as  long  as  the  supply  of  this  from  an  alien  blood 
lasted,  the  patient  did  well.  His  own  tissues  were  ap- 
parently unable  to  furnish  it. 

Purpura,  like  jaundice,  is  usually  a  symptom,  though 
Henoch's  purpura  may  be  classified  as  a  disease  in  it- 
self. This  latter  disease  is  seen  in  children  and  is  ac- 
companied by  intestinal  disturbances,  such  as  pain,  diar- 
rhea and  vomiting,  and  often  by  splenomegalia.  Pur- 


PATHOLOGIC    HEMOEEHAGE.  175 

pura  is  associated  with  various  infections  such  as  sep- 
ticemia,  pyemia,  measles,  scarlet  fever;  or  occurs  after 
some  toxic  or  drug  poison,  as  belladonna,  snake  venom, 
ergot;  or  after  toxins  of  metabolic  disturbances,  as 
Bright 's  disease,  scurvy;  or  after  nervous  affections, 
such  as  locomotor  ataxia  or  transverse  myelitis;  or  it 
may  occur  from  some  derangement  in  the  intestinal 
tract.  The  immediate  treatment  of  purpura  if  hemor- 
rhage is  a  marked  feature,  is  practically  the  same  as  that 
of  bleeding  from  hemophilia.  The  cause,  however, 
should  be  removed  whenever  possible,  and  treatment 
must  be  directed  along  this  line.  Aromatic  sulphuric 
acid  and  turpentine  have  been  recommended  for  pur- 
pura, apparently  on  general  principles. 

Melena  neonatorum  is  probably  merely  another  form 
of  purpura.  Serum  treatment  should  always  be  tried 
and  if  the  hemorrhage  is  severe  and  not  controlled  by  the 
injection  of  fresh  serum,  transfusion  of  blood  should 
be  done.  In  a  young  baby  it  is  necessary  to  use  the  sa- 
phenous  vein  or  the  femoral  for  transfusion. 

Hemorrhage  during  chronic  jaundice  is  always  a  seri- 
ous complication  and  at  least  one-half  of  these  cases  end 
fatally.  Treatment  is  the  same  as  that  of  hemophilia. 
If  operation  is  necessary,  the  patient  should  be  given 
calcium  chloride  or  lactate,  as  recommended  in  the  treat- 
ment of  hemophilia;  also  thyroid  extract  for  two  or  three- 
days  before  operation  seems  beneficial.  Care  should  be 
taken  to  separate  as  few  adhesions  as  possible.  A  hypo- 
dermic injection  of  camphorated  oil,  five  to  ten  minutes 
two  or  three  times  a  day,  acts  as  a  stimulant  and  seems 
to  have  a  beneficial  effect  upon  these  patients. 


CHAPTER  X. 
THROMBOSIS  AND  EMBOLISM. 

Thrombosis. 

The  manner  of  formation  of  a  thrombus  has  been  de- 
scribed in  Chapter  V.  Thrombosis  is  particularly  liable 
to  occur  in  veins,  which  is  largely  due  to  the  sluggish 
circulation  that  permits  comparatively  prolonged  con- 
tact of  blood  cells  with  an  injured  area  of  endothelium. 
In  a  rapid  current,  as  the  arterial  blood,  the  cells  are  in 
contact  for  such  a  short  time  that  there  is  not  the  same 
opportunity  for  damage  to  them.  The  composition  of 
venous  blood  may  also  favor  thrombosis  in  the  veins. 

Venous  thrombosis  is  most  commonly  met  with  as 
phlebitis  in  the  saphenous  or  femoral  vein  of  the  leg,  usu- 
ally of  the  left  leg.  The  lesion  in  the  endothelium  of  the 
vein  may  be  from  trauma  or  from  chemical  or  bacterial 
injury.  The  most  common  cause  of  phlebitis  is  infec- 
tion. The  infection  may  be  mild  but  the  toxin  elabo- 
rated by  the  germs  increases  the  coagulability  of  the 
blood  by  the  destruction  of  blood  cells  which  release 
more  of  the  elements  of  coagulation.  The  vascular 
endothelium  may  be  injured  by  the  contact  of  the 
toxins.  In  the  slow  flow  of  a  venous  stream  a  toxin 
which  is  mildly  irritant  but  which  comes  in  prolonged 
contact  with  the  intima  often  produces  a  slight  change  in 
the  vascular  endothelium  that  is  a  starting  point  for  a 
thrombus.  After  the  thrombus  has  begun  it  extends  by 
additions  to  the  clot  from  the  blood  current  until  the 
whole  vein  may  be  involved. 

176 


THROMBOSIS.  1  <  < 

The  cause  of  the  frequent  involvement  of  the  left  sa- 
phenous  vein  as  compared  with  the  right  is  probably  due 
to  the  slightly  longer  course  of  the  left  vein  before  it 
reaches  the  vena  cava.  The  pressure  of  the  sigmoid 
flexure  may  have  something  to  do  with  it.  Some  cases 
of  phlebitis  are  difficult  to  explain.  A  certain  percentage 
of  abdominal  operations  is  followed  by  phlebitis  of  the 
leg,  even  after  the  wounds  have  healed  by  first  intention. 
It  may  be  possible  that  the  metabolic  products  incident 
to  the  healing  of  the  wound  cause  an  injury  to  the  in- 
tima  of  the  vein  similar  to  that  produced  by  infection. 
Osier  and  others  report  cases  of  thrombosis  of  the  inferior 
vena  cava,  evidenced  by  the  symptoms  and  by  the  super- 
ficial collateral  circulation.  The  sinuses  of  the  dura  are 
also  the  seat  of  thrombosis.  The  lateral  sinus  is  partic- 
ularly liable  to  be  involved  and  this  is  a  serious  condi- 
tion. Septic  clots  often  break  up  and  by  distribution  over 
the  body  cause  pyemia  or  septicemia. 

Thrombosis  of  an  artery  is  not  common.  An  embolus 
usually  derives  its  origin  either  from  a  thrombus  that 
has  formed  in  one  of  the  branches  of  the  pulmonary  veins 
or  from  vegetations  from  the  valves  of  the  heart. 

A  thrombus  is  always  primarily  due  to  some  injury  of 
the  intima  of  the  blood-vessels ;  consequently,  the  throm- 
bus is  secondary.  This  doctrine  was  held  by  John  Hun- 
ter. Virchow,  however,  claimed  that  the  thrombus  was 
usually  primary  and  the  lesion  in  the  vessel  wall  was  sec- 
ondary. This  teaching  has  been  practically  abandoned. 
Adami  *  states  that  a  thrombus  is  always  associated  with 
local  disturbance  of  the  vascular  wall  and  it  is  doubtful 
whether  a  thrombus  ever  originated  as  a  process  of  free 
clotting  of  the  circulating  blood.  While  the  direct  cause 
is  some  injury  to  the  endothelium  of  the  intima,  the  con- 

i  Principles   of   Pathology,   Vol.   II,    page   59. 


178  SURGERY    OF    THE    BLOOD-VESSELS. 

dition  of  the  blood  both  as  to  composition  and  as  to  the 
rate  of  flow,  constitutes  a  very  strong  predisposing 
cause.  Changes  in  the  blood-vessel  that  cause  the  for- 
mation of  a  clot  are  induced  by  direct  trauma  or  by  dis- 
ease of  the  blood-vessel  itself,  as  in  arteriosclerosis  or 
atheroma.  These  changes  may  also  be  secondary  to 
some  irritating  substance  in  the  blood,  derived  from  de- 
ranged metabolic  processes  from  the  ingestion  of  irri- 
tating substances,  or  caused  by  a  toxic  bacterial  product. 
Whether  a  slight  injury  of  the  vascular  wall  is  always 
followed  by  clotting  and  the  exact  extent  of  the  thrombus 
when  formed  depends  upon  the  condition  of  the  blood 
itself.  Thrombosis  frequently  occurs  after  the  acute  in- 
fectious diseases,  such  as  typhoid,  measles,  scarlet  fever, 
smallpox,  and  after  pyogenic  infection.  It  may  occur 
during  gonorrhea,  syphilis,  gout  and  various  forms  of 
anemia,  especially  that  following  hemorrhage.  Most  of 
these  conditions  probably  act  primarily  by  injuring  the 
intima  and  secondarily  by  causing  the  essential  elements 
of  clot  formation  to  be  abundantly  present  in  the  blood. 
It  is  well  known  that  most  of  the  constituents  of  a  throm- 
bus, particularly  nbrinogen,  are  largely  derived  from 
the  disintegration  of  the  blood  cells.  The  presence  of 
toxic  material  in  the  blood  has  a  destructive  effect  upon 
these  cells,  so  a  slight  lesion  of  the  intima  which,  under 
ordinary  conditions,  might  not  cause  thrombosis,  will 
produce  extensive  clotting  when  the  blood  contains  a 
large  amount  of  nbrinogen  and  thrombogen. 

The  changes  in  the  blood  itself  may,  however,  be  of 
such  a  nature  as  to  retard  clotting.  The  absence  of  the 
proper  amount  of  calcium  salts  together  with  the  some- 
what obscure  influence  of  such  diseases  as  malaria,  yel- 
low fever,  scurvy,  jaundice,  hemophilia,  pernicious 
anemia,  leukemia  and  alcoholism  decreases  the  coagula- 


THROMBOSIS.  17(J 

bility  of  the  blood.  An  excessive  amount  of  oxygen,  the 
restriction  of  food,  ingestion  of  large  quantities  of  water, 
smoking  of  tobacco,  are  said  to  delay  clotting.  The  in- 
jection of  certain  chemicals,  particularly  the  extract 
from  the  head  of  a  leech,  called  "hirudin,"  retards  clot- 
ting. The  coagulability  of  the  blood  is  also  delayed  by 
certain  snake  venoms  and  after  poisoning  by  chloroform 
or  prussic  acid.  Clotting  is  accelerated  and  may  possibly 
be  produced  within  the  blood-vessels  by  the  injection 
of  defibrinated  blood  or  an  emulsion  of  leucocytes,  also 
by  the  injection  of  ether,  gallic  acid,  or  the  bile  salts. 
Extensive  burns  and  severe  frost  bites  promote  throm- 
bosis, particularly  in  the  capillaries.  The  use  of  thyroid 
extract,  and  of  gelatin,  and  the  administration  of  milk 
and  lime  salts,  together  with  the  injection  of  a  serum  or 
"coagulos"  in  order  to  increase  clotting  have  been  re- 
ferred to  under  the  head  of  pathologic  hemorrhage. 

Blood  platelets  have  an  important  role  in  thrombosis, 
and  in  the  conditions  in  which  thrombosis  is  most  likely 
to  occur  these  platelets  are  abundant.  Their  exact  ac- 
tion is  a  matter  of  doubt.  They  are  supposed  by  some 
to  result  from  the  destruction  of  the  blood  cells,  whereas 
others  claim  they  are  the  direct  product  of  the  large 
cells  of  the  bone  marrow. 

The  rate  of  flow  of  the  blood  has  a  marked  influence 
upon  thrombosis.  When  the  blood  cells  are  carried  rap- 
idly past  a  lesion  on  the  intima,  there  is  not  enough  time 
for  the  cells  to  be  sufficiently  injured  in  order  to  disin- 
tegrate and  throw  out  the  essentials  of  a  clot.  On  the 
other  hand,  if  the  current  is  slow  and  the  cells  are  in  con- 
tact with  the  lesion  for  some  time,  they  may  disintegrate 
and  the  elements  of  clot  formation  are  rapidly  produced. 
For  this  reason  anything  that  tends  to  retard  the  current 
of  blood  is  a  predisposing  cause  of  thrombosis.  Nat- 


180  SURGERY    OF    THE    BLOOD-VESSELS. 

urally,  under  these  conditions  the  veins  are  the  most  fre- 
quent site  of  thrombus  formation.  Occasionally,  eddies 
or  whirls  in  the  blood  current  favor  the  formation  of 
clots.  This  may  be  due  to  the  fact  that  the  same  blood 
cells,  instead  of  passing  by  the  lesion  of  the  intima  and 
returning  later  after  completing  the  circulation,  are  car- 
ried quickly  back  to  it  by  the  little  eddies  or  whirls. 

A  thrombus  is  usually  classified  as  a  hyaline  thrombus, 
a  white  thrombus,  or  a  red  thrombus.  These  are  sub- 
divided by  various  authors.  The  white  thrombus,  par- 
ticularly as  found  in  aneurisms,  is  probably  a  late  stage 
of  the  red  thrombus,  the  coloring  matter  derived  from 
the  red  blood  cells  having  been  gradually  absorbed. 
However,  under  certain  conditions  the  white  thrombus 
is  deposited  primarily.  The  common  form  of  thrombus 
is  the  red  thrombus.  The  hyaline  thrombus  is  interest- 
ing but  rare.  It  seems  to  be  formed  largely,  if  not  en- 
tirely, from  the  blood  platelets  or  from  the  shadow  cor- 
puscles of  the  red  cells.  They  are  largely  found  after 
some  infectious  disease  or  toxic  material  that  causes 
hemolysis  of  the  red  blood  cells.  The  white  thrombus 
that  occurs  in  the  chambers  of  the  heart  or  in  the  large 
vessels,  is  composed  mainly  of  white  corpuscles  inter- 
mingled with  a  fibrinous  layer.  Under  low  power  of  the 
microscope,  sections  from  a  hyaline  thrombus  appear 
homogeneous,  but  under  high  power  they  are  seen  to  be 
packed  closely  with  blood  platelets  among  which  are  a 
few  white  blood  cells.  This  appearance  may  be  varied 
in  different  portions.  Purely  fibrinous  thrombi  are 
sometimes  seen  in  pulmonary  vessels  after  pneumonia. 

At  the  beginning  of  its  formation,  a  thrombus  is  what 
is  termed  parietal  or  mural  and  does  not  occlude  the 
whole  vessel.  As  it  enlarges,  the  vessel  is  completely 
filled.  Thrombi  sometimes  occur  on  the  valves  of  the 


THEOMBOSIS.  181 

heart  or  the  valves  of  a  vein.  The  term  secondary 
thrombus  is  applied  to  that  formed  around  an  embolus. 
Sometimes  a  thrombus  is  found  loose  in  the  heart,  result- 
ing from  the  detachment  of  a  thrombus  that  forms  in  the 
chambers  of  the  heart.  This  is  called  a  "ball  throm- 
bus." As  a  rule,  however,  thrombi  are  always  adherent 
to  the  interior  of  the  vessel  in  which  they  originate  and 
advance  both  peripherally  and  centrally,  but  extend  most 
rapidly  in  the  direction  of  the  blood  current. 

A  thrombus  which  at  first  is  soft,  later  contracts  and 
becomes  more  compact.  The  leucocytes  undergo  fatty 
degeneration  and  the  red  cells  disintegrate.  The  fibrin 
becomes  coarser  and  so-called  organization  will  later  oc- 
cur, by  which  the  leucocytes  from  the  small  vasa  vaso- 
rum  invade  and  remove  the  clot.  The  intima  of  the  ves- 
sel is  covered  with  granulations  that  replace  the  clot 
which  is  in  time  converted  into  a  string  of  cicatricial 
tissue.  When  the  whole  vessel  is  occluded  it  generally 
becomes  merely  a  fibrinous  cord.  Sometimes  if  all  of 
the  thrombus  is  not  removed,  spaces  will  be  left  which 
communicate  with  the  blood  current,  the  thrombus  may 
present  a  small  lumen  and  the  blood  current  is  partially 
restored.  The  changes  in  a  thrombus  depend  to  a  large 
extent  upon  the  condition  of  the  patient.  Usually,  it  is 
well  advanced  in  a  week.  Sometimes  a  thrombus  is  cal- 
cified, and  remains  as  a  small  round  or  oblong  hard  body 
called  "a  phlebolith"  that  may  either  be  firmly  imbed- 
ded in  the  walls  of  a  vein  which  has  been  obliterated  by 
the  thrombus,  or  merely  loosely  adherent  and  capable  of 
some  motion.  These  are  found  very  frequently  in  the 
venous  plexuses  about  the  broad  ligament  in  women  and 
about  the  prostate  in  men. 

The  change  a  thrombus  undergoes  depends  to  some  ex- 
tent upon  its  position  and  size.  A  small  thrombus  that 


182  SURGERY    OF    THE    BLOOD- VESSELS. 

does  not  entirely  occlude  the  vessels  may  be  completely 
absorbed  either  by  the  leucocytes  with  a  solution  of  the 
fibrin,  or  if  larger  the  thrombus  may  break  down  into  a 
thick,  opaque  fluid  that  is  sterile,  but  resembles  pus  in 
appearance.  It  contains  globules  of  fat,  together  with 
debris  and  some  red  corpuscles,  and  is  the  result  partly 
of  the  work  of  the  leucocytes  and  partly  of  the  digestion 
of  some  ferment. 

The  so-called  organization  of  a  thrombus  is  a  mis- 
nomer, for  the  thrombus  is  absorbed  and  is  replaced  en- 
tirely by  connective  tissue.  Granulations  spring  up 
from  the  surrounding  endothelial  cells.  The  leucocytes 
invade  the  clot  and  carry  it  away  and  the  granulations 
form  connective  tissue.  This  may  convert  the  vessel  into 
a  fibrous  cord,  or  may  result  merely  in  the  formation  of 
bands  or  in  permanent  contraction  of  the  vessel  at  the 
site  of  the  thrombus. 

Canalization  of  the  thrombus  is  an  interesting  but  not 
a  very  common  termination.  In  this  condition  the  cen- 
ter of  the  thrombus  is  pierced  by  a  small  blood-vessel. 
According  to  Adami,  the  most  probable  explanation  is 
that  the  capillaries  which  penetrate  the  thrombus  to 
carry  leucocytes  communicate  with  each  other  and  event- 
ually communicate  with  each  end  of  the  thrombus, 
thereby  establishing  a  channel  which  may  dilate  and 
form  a  larger  vessel.  As  has  already  been  mentioned, 
calcification  of  the  thrombus  may  occur.  An  aseptic 
thrombus  does  not  break  up  as  readily  as  one  that  is 
septic.  A  septic  thrombus  often  goes  to  pieces,  and  so 
spreads  septic  material  in  the  circulation,  causing  py- 
emia ;  or  it  may  be  surrounded  by  a  further  thrombus  not 
septic  which  encapsulates  the  septic  material  and  so  lo- 
calizes it. 

The  cause  of  a  thrombus  has  been  discussed  in  a  gen- 


THROMBOSIS.  1 8.'> 

eral  way,  but  occasionally  thrombi  are  found  tliat  arc 
difficult  to  explain.  The  thrombo-phlebitis  of  the  left- 
leg  following  operations  has  been  referred  to  as  an  ex- 
ample of  this.  Occasionally,  after  an  operation,  espe- 
cially after  an  abdominal  operation,  thrombosis  of  the 
left  femoral  or  saphenous  vein  occurs.  This  is  often 
found  after  slight  suppuration  or  particularly  after  a 
septic  course,  but  not  infrequently  thrombosis  occurs 
when  there  is  evidence  of  a  clean  wound  and  perfect  heal- 
ing. Clark  has  written  extensively  on  this  subject  and 
thinks  thrombosis  is  due  to  the  retractors  which  trau- 
matize the  abdominal  wall  and  cause  thrombosis  of  the 
superficial  or  deep  epigastric  veins,  and  that  this  throm- 
bus extends  to  and  involves  the  iliac  and  femoral  veins. 
He  explains  left-sided  thrombosis  after  an  operation  on 
the  right  side  of  the  abdomen  by  the  free  communication 
between  the  veins  of  the  two  sides.  The  left  side  is  the 
one  most  frequently  involved.  The  reasons  usually 
given  are  that  the  course  of  this  vein  including  the  iliac 
trunk  is  slightly  longer  than  that  on  the  right  side,  it  is 
compressed  by  the  arteries  in  the  pelvis  under  which  it 
passes,  and  often  it  is  also  further  compressed  by  an 
overloaded  sigmoid.  The  symptoms  appear  about  the 
second  or  third  week.  The  left  leg  is  affected  twice  as 
frequently  as  the  right,  and  sometimes  both  legs  are  in- 
volved. The  disease  rarely  begins  earlier  than  eight 
days,  nor  does  it  appear  later  than  thirty.  The  second 
week  after  operation  is  the  most  favorable  time  for  the 
development  of  thrombosis.  Pain  in  the  calf  of  the  leg 
and  tenderness  over  the  course  of  the  saphenous  vein 
which  begin  the  second  week  of  convalescence  from  an 
abdominal  operation  are  always  suggestive  of  phlebitis 
and  if  there  is  a  rise  of  temperature  accompanied  by 
some  swelling,  the  diagnosis  can  readily  be  made. 


184  SURGERY    OF    THE    BLOOD-VESSELS. 

The  treatment  of  this  condition  is  not  very  satisfac- 
tory. Conservative  treatment  consists  of  rest  in  bed, 
elevation  of  the  leg,  enclosing  it  in  cotton,  which  is 
lightly  bandaged,  and  the  application  of  opium  and  lead 
water  or  belladonna  ointment.  These  remedies  usually 
give  relief  in  the  course  of  time,  though  swelling  will  be 
present,  particularly  after  walking,  for  weeks  or  months. 

In  septic  thrombosis  in  the  leg  or  arm,  the  treatment 
should  be  directed  largely  toward  the  source  of  infec- 
tion. If  the  infection  is  in  the  leg  and  the  patient  runs 
a  high  temperature  with  pyemic  symptoms,  the  vein 
should  be  excised  or  ligated,  or  amputation  should  be 
performed  if  the  symptoms  are  severe.  In  amputation 
of  the  leg  in  which  there  is  sepsis  and  thrombosis  of  the 
veins,  great  care  should  be  taken  in  the  operation. 
Eough  handling,  the  application  of  an  Esmarch,  or  even 
a  tourniquet,  may  loosen  the  clots  and  force  into  the  cir- 
culation a  fatal  dose  of  sepsis.  Amputation  in  such  in- 
stances should  be  done  by  the  dissection  method  without 
a  tourniquet,  cutting  the  flaps  carefully  and  controlling 
small  bleeding  points  by  forceps  and  accurately  dis- 
secting out  the  large  vessels,  tying  or  clamping  them 
before  division.  The  limb  should  not  be  moved  until 
it  is  completely  severed  from  the  body.  In  this  way 
but  little  damage  is  done  to  the  tissues,  the  traumatizing 
effect  of  the  tourniquet  is  dispensed  with,  and  the  pos- 
sibility of  the  tourniquet  forcing  septic  thrombi  further 
along  in  the  veins  is  obviated. 

In  thrombosis  of  the  lateral  sinus  and  the  internal 
jugular  vein,  which  most  frequently  occurs  as  a  result 
of  sepsis  following  mastoid  or  middle  ear  suppurative 
disease,  the  vein  should  be  promptly  ligated  or  excised. 
Manipulation  must  be  as  gentle  as  possible,  first  expos- 
ing the  vein  near  the  root  of  the  neck  and  ligating  it  be- 


EMBOLISM.  185 

fore  any  clot  is  dislodged.  In  one  case  of  thrombosis  of 
the  internal  jugular  from  a  mastoid  suppuration,  the  au- 
thor excised  the  jugular;  in  another  instance  when 
sepsis  came  from  the  lower  jaw,  the  jugular  was  care- 
fully dissected  free  and  the  branches  which  emptied  into 
it  were  ligated.  Both  patients  were  very  septic  witli 
rapid  and  feeble  pulse.  Both  recovered  after  a  stormy 
convalescence. 

Embolism. 

Embolism  literally  means  blockage  of  an  artery  or  vein 
by  some  substance  that  did  not  originate  in  the  region 
at  which  the  blockage  occurs.  The  substance  is  the  em- 
bolus.  The  most  frequent  source  of  an  embolus  is  a 
thrombus,  particularly  a  septic  thrombus  which  easily 
breaks  up  and  gives  rise  to  showers  of  small  clots  that 
form  emboli.  This  is  the  generally  accepted  description 
of  pyemia.  Emboli  more  commonly  come  from  a  throm- 
bus, but  may  be  from  fat,  air,  pieces  of  foreign  body, 
portions  of  a  tumor,  or  parasites.  The  formation  of  an 
aneurism  in  the  mesenteric  artery  of  a  horse  from  the 
strongylus  armatu-s  is  a  well  known  example  of  an  embo- 
lus from  a  parasite.  Pieces  of  tumor  or  calcareous  mat- 
ter or,  occasionally,  in  leukemia,  large  masses  of  leuco- 
cytes may  form  emboli.  Cases  have  been  recorded  in 
which  a  bullet  entering  the  heart  or  large  blood-vessels 
has  acted  as  an  embolus  and  has  been  carried  by  the 
blood  stream  until  arrested  by  the  narrowing  caliber  of 
the  artery. 

Naturally,  emboli  occur  more  frequently  in  arteries 
than  in  veins,  though  venous  emboli  are  by  no  means  un- 
common. The  portal  vein  is  particularly  liable  to  em- 
boli because  it  acts  somewhat  as  an  artery  by  receiving 
blood  and  eventually  emptying  it  into  smaller  channels. 


186  SURGERY    OF    THE    BLOOD-VESSELS. 

Venous  emboli  in  the  general  circulation  occur  in  two 
ways,  by  retrograde  movement  in  which  the  current  of 
blood  is  temporarily  reversed,  and  by  the  persistence  of 
the  foramen  ovale  through  which  a  thrombus  may  be 
forced  back  into  a  vein. 

Cardiac  emboli  are  very  rare,  because  even  a  large 
thrombus  from  a  vein  is  usually  carried  through  the 
heart  and  arrested  in  the  pulmonary  arteries.  Some- 
times, however,  the  heart  may  be  completely  blocked, 
which,  of  course,  results  in  sudden  death.  Emboli  are 
more  likely  to  lodge  in  the  arteries  of  the  lower  extremi- 
ties because  of  the  fact  that  their  large  vessels  are  more 
directly  in  the  axis  of  the  main  arterial  current.  It  is 
probable  that  many  emboli  carried  into  the  legs  do  not 
give  serious  symptoms,  and  as  an  embolus  in  the  cerebral 
or  in  the  mesenteric  arteries  is  usually  a  very  grave 
or  a  fatal  condition,  the  incidence  of  emboli  in  these  lat- 
ter situations  has  appeared  abnormally  great.  The  pul- 
monary artery  is  frequently  the  site  of  emboli  from  a 
detached  thrombus  that  goes  from  the  systemic  veins 
into  the  right  side  of  the  heart. 

Welch,  whose  classical  article  on  thrombosis  and  em- 
bolism in  Albutt's  " System  of  Medicine"  is  the  basis  of 
most  writings  on  this  subject,  believes  that  embolism  is 
most  frequently  detected  in  the  renal,  splenic,  cerebral, 
iliac,  and  other  arteries  of  the  lower  extremity,  axillary 
arteries  of  the  upper  extremity,  ceoliac  axis,  the  central 
artery  of  the  retina,  the  superior  mesenteric,  the  inferior 
mesenteric,  the  abdominal  aorta,  and  the  cardiac  coronary 
arteries.  This,  he  says,  is  the  relative  order  of  frequency 
so  far  as  symptoms  appear,  though  more  than  likely  the 
actual  occurrence  of  embolism  is  in  a  different  ratio  as  has 
already  been  explained,  because  of  the  fact  that  in  many 
of  the  arteries  first  mentioned  the  slightest  embolus  will 


EMBOLISM.  187 

give  symptoms,  whereas  an  embolus  may  occur  in  ar- 
teries of  the  lower  extremities  with  but  few  if  any  symp- 
toms. A  "paradoxical"  or  "crossed"  embolus  results 
from  a  thrombus  that  originated  in  the  venous  side  and 
is  found  plugging  one  of  the  systemic  arteries.  This,  of 
course,  can  only  take  place  by  the  passage  of  the  embo- 
lus through  the  patent  foramen  ovale.  The  persistence 
of  a  patent  foramen  ovale  is  by  no  means  uncommon  and 
it  is  said  that  in  one  out  of  three  hearts  some  such  com- 
munication exists,  though  it  is  usually  small  and  valve- 
like.  In  some  cases,  however,  it  is  large  and  direct. 

The  capillaries  of  the  lungs  are  quite  large  and  easily 
distended.  It  is  possible  for  articles  of  considerable 
size,  even  tissue  cells,  to  pass  through  the  capillaries  of 
the  lungs  without  being  arrested.  Adami  mentions  an 
experiment  in  which  scraped  material  from  the  liver  of  a 
rabbit  was  injected  into  the  systemic  vein  of  another 
rabbit.  After  a  few  minutes  the  second  rabbit  was  killed 
and  small  masses  of  liver  cells  were  found  in  the  arteri- 
oles  of  the  kidney.  Examination  of  the  heart  showed 
the  foramen  ovale  was  closed. 

Capillary  emboli  occur  from  small  masses  that  are 
numerous  and  yet  are  not  large  enough  to  arrest  the  cir- 
culation in  a  large  artery.  It  has  been  noticed  that  the 
pigment  remains  of  the  malarial  parasite  may  be  ar- 
rested in  the  fine  capillaries  of  the  brain  and  kidney,  re- 
sulting in  functional  disturbance  of  these  organs.  Bac- 
teria and  cells  from  malignant  tumors  often  form  emboli 
in  the  capillaries. 

The  presence  of  air  as  emboli  is  more  or  less  danger- 
ous, depending  upon  the  vein  into  which  the  air  was 
taken,  and  the  suddenness  of  the  intake  as  well  as 
the  amount  of  air  aspirated.  Such  an  accident  was 
not  uncommon  in  preanesthetic  days,  when  the  patient 


188  SURGERY    OF    THE    BLOOD-VESSELS. 

would  often  hold  his  breath  from  the  pain  and  suddenly 
take  a  deep  inspiration.  The  hissing,  sucking  sound  of 
the  air  entering  is  very  noticeable.  The  slow  entrance 
of  air  into  a  vein  at  some  distance  from  the  heart  can 
usually  be  taken  care  of  without  any  untoward  event. 
Nitrogen  and  oxygen  are  normally  carried  in  solution  in 
the  blood  stream,  either  in  combination  with  the  cells  or 
in  the  plasma  of  the  blood,  and  a  small  amount  of  air 
introduced  slowly  is  readily  dissolved.  The  amount  of 
air  that  can  be  given  in  an  ordinary  hypodermic  syringe, 
if  injected  slowly  into  a  distal  vein,  would  in  all  proba- 
bility occasion  but  little  if  any  disturbance.  However, 
air  injected  suddenly  into  the  veins  of  the  neck  near  the 
heart  produces  serious  symptoms  at  once.  Formerly 
many  deaths  from  supposed  air  embolism  were  probably 
cases  in  which  gas  formed  after  death,  such  as  occurs 
from  the  bacillus  aerogenes  capsulatus,  but  even  includ- 
ing such  instances  death  from  air  embolus  has  undoubt- 
edly been  more  frequent  in  preanesthetic  days  than  now. 
Air  when  taken  in  and  warmed  by  the  temperature  of  the 
blood  expands  and  forms  a  much  larger  volume  than  it 
would  naturally  have  in  the  normal  temperature  of  the 
room. 

Though  air  embolism  is  not  common,  such  accidents 
occasionally  occur  now.  Within  the  last  ten  years  the 
author  has  had  two  cases,  one  of  them  terminating  fa- 
tally. In  this  case  the  author  operated  upon  the  neck 
for  a  large  recurrent  carcinoma,  which  had  infiltrated 
and  blocked  the  internal  jugular  vein.  Contraction  of 
the  cancer  had  distorted  the  anatomy  and  pulled  the 
internal  jugular  considerably  out  of  its  normal  posi- 
tion. As  the  head  of  the  patient  was  slightly  elevated 
and  the  vein  blocked  it  was  constantly  collapsed  and  re- 
sembled a  band  of  fascia.  In  an  effort  to  dissect  the 


EMBOLISM.  IS!) 

common  carotid,  this  vein  was  cut,  as  it  seemed  merely  a 
band  of  connective  tissue.  It  was  picked  up  and  was  seen 
to  have  a  shining  internal  surface.  Air  rushed  in  imme- 
diately and  the  vein  was  then  clamped.  It  was  recog- 
nized at  once  that  a  mistake  had  been  made,  though  no 
blood  at  any  time  escaped  through  the  vein.  The  pa- 
tient's head  was  lowered  and  he  seemed  to  improve  for  a 
short  while.  He  was  given  intravenous  salt  solution 
with  adrenalin  and  his  pulse  was  better  for  about  five 
minutes.  Then  his  head  was  raised  and  his  pulse  be- 
came weaker.  He  died  in  about  fifteen  minutes  from  the 
time  the  vein  was  cut. 

In  the  second  case,  during  a  dissection  of  tubercular 
sinuses  and  tissue  over  the  sternum  where  there  were  sev- 
eral superficial  veins,  one  of  them  was  cut  and  immedi- 
ately the  hissing  sound  of  air  entering  the  vein  was 
heard.  The  vein  was  at  once  compressed  with  the  finger 
and  then  a  wet  compress  was  placed  upon  it  and  the  tis- 
sue sutured.  The  patient's  pulse  became  rapid  and 
rather  weak,  though  after  a  few  minutes  it  improved 
and  he  made  a  satisfactory  recovery. 

The  mode  of  death  after  air  embolism  has  been  a  sub- 
ject of  considerable  controversy.  The  two  main  theo- 
ries are,  first,  that  it  is  a  cardiac  death.  The  air  is 
warmed  and  expands  rapidly.  It  accumulates  behind 
the  tricuspid  valves  and  renders  them  inefficient.  The 
pressor  terminals  in  the  heart  are  unaccustomed  to  air 
instead  of  fluid  blood  and  are  also  deranged.  The  second 
theory  is  that  death  is  caused  by  multiple  air  emboli  in 
the  pulmonary  capillaries  of  the  lungs.  These  small 
bubbles  of  air  cannot  pass  through  the  capillaries  of  the 
lung  but  block  them;  thus  death  occurs  in  the  same  man- 
ner as  when  the  pulmonary  arteries  themselves  are  oc- 
cluded. It  is  thought  by  some  that  gas  may  eventually 


190  SURGERY    OF    THE    BLOOD-VESSELS. 

make  its  way  to  the  left  side  of  the  heart  and  that  the 
emboli  in  the  brain  may  be  the  cause  of  death.  This 
is  not  as  probable  as  the  other  two  theories  and  accord- 
ing to  the  experiments  of  Wolff  the  theory  of  death  from 
air  emboli  in  the  pulmonary  capillaries  is  more  reason- 
able. 

A  form  of  embolism  from  air  or  from  gas  that  is  fre- 
quently fatal  occurs  in  those  who  work  in  compressed  air 
and  is  supposed  by  many  to  be  the  cause  of  the  so-called 
''caisson  disease."  After  working  in  compressed  air  for 
some  time  if  the  individual  emerges  suddenly  he  often  be- 
comes a  victim  of  nervous  disturbances  that  may  quickly 
prove  fatal.  There  are  various  paralyses  and  other 
symptoms  showing  lesions  of  the  spinal  cord.  These 
are  probably  due  to  the  fact  that  the  tissues  take  up 
under  increased  pressure  much  more  gas  than  under  or- 
dinary atmospheric  pressure,  and  when  the  pressure  is 
suddenly  removed  the  gas  is  released.  If  the  pressure 
is  quickly  reduced,  the  blood  and  tissues  can  no  longer 
hold  the  excess  of  free  nitrogen  in  solution,  though  the 
oxygen  may  be  taken  care  of.  The  nitrogen  separates 
in  the  form  of  bubbles  that  grow  in  size  as  the  pressure 
is  diminished  and  are  carried  by  the  blood  stream,  form- 
ing gas  emboli.  This  is  most  serious  when  the  brain 
and  spinal  cord  are  affected. 

The  results  of  emboli  depend  upon  their  location  and 
are  the  same  as  after  occlusion  of  an  artery.  If  derived 
from  a  thrombus,  the  changes  and  termination  following 
the  localization  of  the  emboli  depend  partly  upon  whether 
there  is  infection  and  whether  the  infection  is  localized 
by  a  sterile  layer  of  thrombus  around  the  infected  ma- 
terial. 

The  treatment  of  embolism  depends  upon  its  form  and 
location.  In  air  embolism  various  suggestions  have  been 


EMBOLISM.  li'l 

made.  One  is  that  a  rubber  tube  or  catheter  be  inserted 
in  the  right  internal  jugular  vein  and  pushed  into  the 
heart,  the  air  being  drawn  off  by  this  means.  It  is 
rather  impracticable,  for  it  is  likely  that  more  air  will  be 
introduced  by  this  method,  particularly  as  the  tube  will 
probably  not  fit  the  vein  accurately.  The  main  treat- 
ment should  be  directed  toward  general  stimulation  of 
the  heart,  together  with  lowering  -the  head,  and  the  ad- 
ministration of  oxygen.  The  heart  is  stimulated  in  or- 
der to  prevent  collapse  and  at  the  same  time  to  force 
the  air  through  the  capillaries  of  the  lungs  and  to  hasten 
its  solution  in  the  blood  stream.  Of  course,  the  imme- 
diate treatment  at  the  wound  consists  in  pressure  on  the 
injured  vein.  This  should  be  done  with  the  finger  at 
first  and  later  with  a  moist  compress  which  is  fastened 
securely  in  position  for  several  days.  Usually  the  trunk 
of  the  vein  can  be  compressed  toward  the  heart  and  the 
vein  clamped  and  tied;  though  the  application  of  a  moist 
compress  or  the  finger  should  be  maintained  until  the 
patient  has  somewhat  reacted  or  until  it  is  entirely  cer- 
tain that  ligation  or  clamping  can  be  done  without  the 
possibility  of  more  air  entering. 

The  preventive  treatment  of  air  embolism  should  be 
borne  in  mind  when  operating  on  the  neck  and  in  the 
axilla,  as  only  the  regions  that  are  nearest  the  heart  and 
consequently  subject  to  the  so-called  venous  pulse  are  in 
danger  of  admitting  air.  The  deep  jugular  vein  is  fixed 
rather  firmly  to  the  fascial  planes  of  the  neck,  which  to 
some  extent  prevents  it  from  collapsing  readily.  When 
such  a  vein  is  inflamed  and  the  walls  made  stiff,  the  dan- 
ger is  still  greater.  In  injuries  to  the  femoral  or  saphe- 
nous  veins  or  even  to  the  veins  in  the  pelvis  there  is  but 
a  slight  chance  of  air  embolism,  though  such  cases  have 
been  reported.  Usually  here  the  pressure  is  positive 


192  SURGERY    OF    THE    BLOOD-VESSELS. 

and  the  distance  is  too  great  from  the  heart  for  the  ve- 
nous pulse.  In  operations  upon  the  neck  or  axilla  the 
incision  should  be  sufficiently  long  to  enable  the  operator 
to  identify  the  structures.  It  is  best  to  make  the  incision 
low  in  the  neck  first  and  if  the  internal  jugular  is  not 
distended,  a  sponge  or  a  wad  of  gauze  shoved  in  behind 
the  clavicle,  as  suggested  by  Mayo,  will  produce  enough 
pressure  upon  the  vein  to  keep  it  distended.  With  ordi- 
nary skill  there  should  be  no  danger  in  dissecting  a  dis- 
tended jugular  vein.  It  is  when  it  becomes  collapsed 
that  there  is  great  risk  of  injury. 

Fat  embolism  occurs  from  the  rupture  of  fat  cells  and 
the  discharge  of  their  contents  into  the  blood  stream.  It 
comes  on  particularly  after  injuries  to  long  bones  in 
which  the  fat  marrow  is  involved,  for  the  veins  in  the 
haversian  canals  cannot  readily  collapse  as  they  are  fixed 
to  the  bony  wall.  It  may  result  from  injuries  to  the 
mesentery  or  to  the  fat  beneath  the  skin. 

Fat  embolism  appears  later  than  shock  or  air  embo- 
lism and  except  in  the  region  drained  by  the  portal  vein 
it  is  always  found  first  in  the  lungs.  About  sixty  per- 
cent of  all  cases  are  caused  by  fractures  and  about  sev- 
enty-five percent  are  caused  either  by  fractures  or  by 
some  inflammatory  disease  of  the  bone.  Other  cases  are 
due  to  injuries  or  suppuration  of  the  soft  parts.  The 
fat  from  fracture  of  a  bone  enters  the  veins  about  the 
third  day  after  the  injury  because  the  veins  in  the 
haversian  canals  are  held  open  by  the  bone  and  so 
are  prevented  from  collapsing  and  their  thrombi  may 
loosen  at  this  time.  Fat  embolism  occurs  as  a  rule  from 
thirty-six  to  seventy-two  hours  after  injury,  though  oc- 
casionally it  may  be  much  later.  There  may  be  death 
from  the  sudden  blocking  of  the  pulmonary  vessels.  The 


EMBOLISM.  193 

symptoms  are  usually  pulmonary  at  first,  severe  pain  in 
the  chest,  difficult  breathing,  cyanosis,  and  sometimes 
expectoration  of  blood.  Temperature  at  first  is  subnor- 
mal but  soon  rises.  The  physical  signs  are  rather  in- 
definite, though  there  are  many  coarse  rales  and  later 
consolidation  occurs.  If  the  patient  does  not  die  soon 
some  of  the  fat  is  forced  through  into  the  systemic  cir- 
culation and  symptoms  of  embolism  of  the  brain,  such 
as  convulsions,  paralyses,  or  coma,  may  occur.  The  kid- 
neys are  also  affected  and  often  fat  may  be  demonstrated 
in  the  urine.  Fat,  however,  is  frequently  found  in  the 
urine  in  small  amounts  after  fractures  when  there  are 
no  symptoms  of  embolism.  It  is  probable  a  great  many 
cases  of  fat  embolism  occur  that  produce  such  slight 
symptoms  they  are  not  recognized.  Only  the  severe  cases 
are  reported. 

The  treatment  of  fat  embolism  consists  partly  of  pre- 
ventive measures,  such  as  avoiding  unnecessary  injury 
to  fat  during  operations,  particularly  to  the  fat  marrow 
of  bone.  Large  quantities  of  fat  when  injured  should  be 
drained.  It  is  well  not  to  sew  fat  but  if  sutured  the  ten- 
sion on  the  stitches  should  be  very  slight.  Several  cases 
of  fat  embolism  have  been  reported  after  so-called  blood- 
less operations  for  congenital  dislocation  of  the  hip,  and 
it  is  one  of  the  dangers  of  this  procedure.  Kiener  ad- 
vises placing  a  constricting  band  to  render  the  limb  blood- 
less and  after  the  operation,  before  the  band  is  removed, 
he  inserts  a  cannula  into  the  upper  end  of  the  saphenous 
vein  pushing  it  on  to  the  femoral  and  so  draws  off  the 
first  flow  of  blood,  which  is  supposed  to  contain  fat.  This, 
however,  is  very  radical.  Treatment  on  general  princi- 
ples is  about  all  that  can  be  done.  Cardiac  stimulation, 
artificial  respiration  if  necessary,  and  the  administration 


194  SURGERY    OP    THE    BLOOD-VESSELS. 

of  oxygen  are  indicated.  Oxygen  not  only  makes  the 
most  of  the  impaired  lung  that  is  left,  but  tends  to  favor 
the  elimination  of  fat  by  oxidation. 

Pulmonary  Embolism. 

Pulmonary  embolism  occupies  a  unique  position  be- 
cause embolism  here  occurs  in  an  artery,  usually  from  a 
thrombus  formed  in  some  of  the  systemic  veins.  It  is 
a  condition  that  often  comes  without  warning  in  a  patient 
who  is  apparently  convalescing  satisfactorily.  For  this 
reason  it  is  peculiarly  distressing  and  tragic.  The  em- 
bolus  originates  from  a  systemic  vein  or  from  the  heart 
and  while  it  may  be  composed  of  various  substances  it 
is  usually  from  the  loosened  clot  of  a  thrombus.  What- 
ever predisposes  to  the  formation  of  a  thrombus,  neces- 
sarily tends  towards  causing  pulmonary  embolism. 
Phlebitis,  whether  traumatic  or  septic,  and  operations 
involving  a  venous  plexus  are  marked  predisposing 
causes.  More  than  one-half  of  all  cases  of  pulmonary 
embolism  are  from  operations  upon  the  uterus  or  its  an- 
nexa.  The  appendix  is  drained  by  the  portal  circula- 
tion, but  thrombosis  of  the  systemic  veins  may  occur 
after  operations  on  the  appendix,  as  explained  under 
"thrombosis"  (page  183).  Hysterectomy  is  responsible 
for  about  one-third  of  the  cases,  and  appendicitis  for 
about  one-tenth.  Two  fatal  cases  of  the  author's  fol- 
lowed suprapubic  cystotomies.  When  operation  is  fol- 
lowed by  the  necessity  of  remaining  in  bed  for  a  long 
time  with  slow  blood  current  in  the  veins,  the  possibility 
of  a  loosened  thrombus  is  much  greater. 

The  symptoms  of  pulmonary  embolism  depend,  of 
course,  upon  the  effect  on  the  lung  and  this  in  turn  upon 
the  size  of  the  embolus  and  the  location  of  the  obstruc- 
tion. Undoubtedly  many  minute  emboli  occur  without 


PULMONARY    EMBOLISM. 

any  obvious  symptoms.  Very  probably  the  pain  in  the 
side  of  the  chest  that  patients  often  complain  of  after 
operation  is  due  to  a  slight  enibolus  near  the  pleur;1,, 
though  if  small  the  physical  signs  may  not  be  noted. 
Larger  emboli  give  more  symptoms  with  an  area  of  con- 
solidation. If  there  is  sepsis  the  symptoms  and  signs  of 
septic  pneumonia  are  present,  but  if  the  emboli  do  not 
contain  septic  germs,  the  symptoms  will  be  dependent 
upon  the  size  of  the  embolus  and  the  amount  of  lung1 
tissue  that  is  put  out  of  commission.  Sometimes  bloody 
expectoration  occurs. 

The  larger  emboli  either  cause  instant  death  or  death 
within  a  few  minutes.  This  occurs  most  frequently  from 
the  second  to  the  fourth  week  after  operation.  The  pa- 
tient may  be  feeling  perfectly  well,  but  following  some 
operation  upon  the  pelvic  organs,  he  sits  up,  the  thrombus 
is  loosened  and  lodges  in  the  pulmonary  arteries.  The 
patient  complains  of  pain  about  the  heart  and  becomes 
purple,  the  pulse  ceases  and  if  the  embolus  is  large  death 
occurs  in  a  few  minutes.  If  the  pulmonary  artery  is  nut 
entirely  plugged  he  may  live  for  hours  or  sometimes 
even  for  days.  Occasionally,  recovery  after  the  most 
alarming  symptoms  has  been  noted.  The  patient  is  cya- 
notic,  respirations  are  rapid,  and  the  eyes  protrude. 
The  pulse  is  very  weak,  quick  and  irregular.  The  pupils 
dilate  and  the  veins  in  the  neck  are  swollen.  The  pa- 
tient is  covered  with  a  cold  sweat.  Occasionally  there  is 
delirium,  coma,  or  convulsions  if  death  is  not  immediate. 
These  symptoms  occurring  suddenly  and  after  rather 
quick  movement  of  the  body  or  legs,  such  as  the  first  ef- 
fort to  rise  in  bed,  make  the  diagnosis  almost  certain. 

The  treatment  depends  upon  the  type  of  case.  If  the 
embolus  is  small  and  symptoms  slight,  treatment  on  gen- 
eral principles  is  all  that  can  be  done.  Cardiac  stim- 


196  SURGERY    OF    THE    BLOOD-VESSELS. 

ulants  together  with  the  proper  nourishment  to  carry 
the  patient  over  the  critical  stage  and  prevent  infec- 
tion are  indicated.  Possibly  the  administration  of  large 
doses  of  urotropin,  fifteen  or  twenty  grains  four  times 
a  day  for  two  days,  which  is  partly  eliminated  from 
the  mucous  membrane  of  the  bronchi  is  also  advis- 
able. The  preventive  treatment  has  already  been  men- 
tioned under  "thrombosis."  It  has  been  advised  to  give 
citric  acid  several  times  a  day  in  such  diseases  as  ty- 
phoid where  there  seems  to  be  an  increased  tendency  to 
clotting.  Decalcifying  milk  by  adding  citrate  of  soda 
has  also  been  suggested  as  the  lactate  of  calcium  in- 
creases clotting  and  the  citrate  of  soda  is  supposed  to 
neutralize  the  effect  of  the  lactate  of  calcium.  If  sepsis 
occurs  the  ordinary  treatment  for  pneumonia  is  carried 
out.  In  large  emboli  oxygen  and  cardiac  stimulants 
should  be  given. 

Direct  treatment  has  been  advocated  by  Trendelen- 
burg.  He  has  elaborated  an  operation  based  on  experi- 
mental work.  He  introduced  into  the  internal  jugular 
vein  of  a  calf  a  piece  of  lung  tissue  aseptically  removed 
from  another  animal.  As  soon  as  the  symptoms  of  pul- 
monary embolism  appeared,  operation  was  done  and  the 
embolus  removed.  The  calf,  wThich  was  eight  weeks  old, 
recovered  from  the  operation  and  three  months  later 
was  killed  and  the  specimen  consisting  of  the  heart  and 
large  blood-vessels  adjoining  was  exhibited  before  the 
German  Surgical  Congress  at  Berlin  in  April,  1908. 
The  technique  of  this  operation  wliich  is  from  the  de- 
scription by  Willy  Myer  2  is  as  follows : 

A  horizontal  incision  about  four  inches  long  is  made 
upon  the  second  rib  on  the  left  side,  beginning  at  the  left 
border  of  the  sternum  and  dividing  the  skin,  fascia,  and 

2  Annals  of    Surgery,   August,    1913. 


PULMONARY    EMBOLISM. 


197 


pectoralis  major  muscle.  This  incision  is  crossed  l>y  a 
perpendicular  cut  which  begins  below  the  sternoclavic- 
ular  articulation  and  passes  the  cartilage  of  the  third 
rib  about  one  inch  outside  of  the  border  of  the  sternum. 
It  so  avoids  the  internal  mammary  artery  (Fig.  (>-). 
The  two  triangular  flaps  formed  by  this  T-shapcd  in 


Fig.  62. — Various  incisions  for  approaching  the  heart  and  pulmonary  artery.  That 
marked  in  a  heavy  line  on  patient's  left  is  the  incision  of  Trendelenburg  for 
extracting  a  pulmonary  emholus. 

cision  are  then  turned  back.  The  second  rib  is  isolated 
and  divided  at  the  external  end  of  the  incision.  The  rib 
is  raised,  twisted  loose  from  its  cartilage,  and  removed. 
The  cartilage  is  then  removed.  The  third  cartilage  is 
divided  in  a  perpendicular  line  to  give  more  space.  If 
the  pleura  has  not  been  opened  by  this  time  a  T-shaped 
incision  should  be  made  through  it  corresponding  to  the 
original  incision.  The  lung  is  allowed  to  collapse,  which 
exposes  the  pericardium.  The  phrenic  nerve  and  pul- 


198 


SUKGERY    OF    THE    BLOOD-VESSELS. 


monary  vessels  are  easily  seen.  The  pericardium  is  di- 
vided just  internal  to  the  phrenic  nerve.  The  wound  is 
lengthened  in  an  upward  and  backward  direction  until 
the  entire  upper  half  of  the  pericardium  is  incised.  The 
lower  portion  is  not  cut  and  the  heart  is  left  in  its  normal 
position.  All  this  is  supposed  to  be  done  in  five  minutes. 
If  ppssible  either  intratrachial  anesthesia  or  differential 


on  the  extreme  right.      (After  Willy   Myer.) 


Fig. 


pressure  should  be  used,  but  it  is  not  necessary.  With 
the  help  of  an  instrument  devised  by  Trendelenburg  and 
called  a  sound,  a  rubber  tube  is  quickly  drawn  through 
the  transverse  sinus  of  the  pericardium  surrounding  the 
ascending  aorta  and  the  pulmonary  artery  and  is  pulled 
up  for  compression  immediately  before  the  surgeon  in- 
cises the  pulmonary  artery.  A  thin  layer  of  fat  with  the 


PULMONARY    EMBOLISM. 


1!)!) 


Fig 


ig.    64. — Pulmonary    artery    has    been    incised    and    forceps    inserted    to    remove    the 
embolus.      (Willy    Myer.) 


200  SURGERY    OF    THE    BLOOD-VESSELS. 

viscera  layer  of  pericardium  is  torn  through  and  an  in- 
cision of  about  one-half  inch  is  made  in  the  pulmonary 
artery.  A  special  curved  blunt  forceps  (Fig.  63)  is  in- 
troduced first  into  the  main  trunk  of  the  pulmonary  artery 
and  then  into  the  branches  and  any  embolus  or  thrombus 
is  grasped  and  extracted  (Fig.  64).  This  must  be  done 
in  forty-five  seconds  because  interruption  of  the  general 
circulation  is  not  tolerated  longer.  The  margins  of  the 
wound  in  the  vessel  are  then  lifted  by  special  forceps 
(Fig.  63),  and  closed  by  a  clamp,  after  which  the  assist- 
ant relaxes  the  elastic  compression  (Fig.  65).  The  cir- 
culation is  thus  reestablished  and  the  heart  begins  to 
beat  very  violently  if  it  has  not  altogether  ceased.  If 
necessary,  the  constriction  can  again  be  tightened  and 
another  search  made  for  the  embolus,  though  the  circula- 
tion must  never  be  cut  off  for  more  than  forty-five  sec- 
onds at  any  one  time.  Closure  of  the  wound  in  the  pul- 
monary artery  is  done  by  interrupted  stitches,  while  the 
clamp  partly  but  not  completely  constricts  the  pulmo- 
nary artery.  The  wound  in  the  artery  should  be  quickly 
sutured,  using  fine  silk.  The  pericardium  and  chest 
wounds  are  closed  in  the  usual  way. 

According  to  Trendelenburg,  in  fifty  percent  of  pul- 
monary embolisms  only  one  branch  of  the  pulmonary 
artery  is  first  obstructed  and  here  death  does  not  occur 
until  ten  to  sixty  minutes  after  the  first  onset  of  symp- 
toms. Fifteen  minutes  is  supposed  to  be  at  the  disposal 
of  the  surgeon  in  most  of  these  cases  and,  with  prompt 
operation,  Trendelenburg  claims  some  patients  can  be 
saved.  The  results  of  the  operation  show  that  no  pa- 
tient so  far  has  survived,  though  one  lived  for  four  days 
and  another  died  from  pneumonia  five  days  after  opera- 
tion. Twelve  cases  in  all  have  been  operated  upon  at 
Trendelenburg 's  clinic  without  a  permanent  recovery. 


PULMONARY   EMBOLISM. 


201 


Fig.  65. — The  embolus  has  been  removed  and  the  incision  has  been  temporarily 
closed  by  a  rubber  covered  clamp.  It  should  now  be  sutured.  Insert  on 
lower  right  shows  forceps  (illustrated  in  Fig.  63)  keeping  the  incision  open 
and  elevating  it  so  it  can  be  grasped  bv  the  forceps  for  temporary  closure. 
(Willy  Myer.) 


202  SURGERY    OF    THE    BLOOD-VESSELS. 

The  suddenness  of  the  symptoms,  the  difficulty  of  the  op- 
eration, the  necessity  for  trained  assistants,  make  it  un- 
likely that  such  a  procedure  can  be  followed  by  success 
except  under  extraordinary  conditions. 


CHAPTER  XL 

TREATMENT   OF   OCCLUSION   OF   THE   MESKX- 

TERIC    BLOOD-VESSELS;    RESECTION    AND 

TRANSPLANTATION  OF  INTESTINE. 

Thrombosis  or  embolism  of  the  mesenteric  vessels  is 
always  serious  whether  due  to  a  septic  or  an  aseptic 
thrombus.  The  blood  supply  to  the  intestinal  tract  is 
practically  terminal  and  the  occlusion  of  even  a  small 
branch  of  the  superior  mesenteric  artery  usually  results 
in  gangrene  of  the  intestine.  Thrombi  may  begin  from 
injury  to  the  artery  or  vein  and  both  the  artery  and  vein 
may  be  occluded.  So  far  as  the  effect  upon  the  intestine 
is  concerned  the  treatment  would  be  the  same  whether 
the  vessels  are  occluded  by  thrombi  or  emboli.  Throm- 
bosis occurs  from  local  disease  in  the  vessel  wall,  from 
injury  such  as  a  blow  or  a  wound,  from  volvulus,  or  par- 
ticularly from  compression  by  a  hernial  ring  as  in 
strangulation. 

One  of  the  author's  cases  followed  reduction  of  a 
strangulated  hernia.  The  constriction  from  a  strangu- 
lated hernia,  particularly  in  a  stout  man,  is  often  severe 
enough  to  injure  the  intima  of  the  artery  or  vein  and 
even  after  the  intestine  is  returned  thrombosis  may  oc- 
cur and  gangrene  result.  The  symptoms  are  sometimes 
difficult  to  differentiate  from  those  of  acute  obstruction 
as  indeed  obstruction  sooner  or  later  develops.  At  first 
the  temperature  is  subnormal,  but  rises  when  peritonitis 
sets  in.  In  the  early  stages,  however,  there  is  intense 
pain  of  a  colicky  nature,  more  or  less  intermittent;  usu- 

203 


SURGERY    OF    THE    BLOOD-VESSELS. 

ally  there  is  vomiting,  and  sometimes  the  passage  of  a 
bloody  stool.  Occasionally  a  mass  may  be  felt  in  the  ab- 
domen. The  abdomen  is  rigid  and  there  is  no  distention 
at  first.  If  this  occurs  in  a  child,  intussusception  is  sus- 
pected. If  in  an  adult,  particularly  after  a  history  of 
trauma  or  hernia,  thrombosis  or  some  obstruction  of  the 
mesenteric  arteries  or  veins  must  be  borne  in  mind. 

Treatment  of  this  condition  consists  solely  in  opera- 
tion. On  abdominal  section  the  affected  intestine  is  seen 
to  be  a  different  color  from  the  neighboring  loops.  It  is 
dark  red  or  even  black  and  gangrenous.  It  is  Usually 
not  adherent  at  first  and  is  readily  brought  into  the 
wound.  It  should  be  excised  as  promptly  as  possible 
but  the  greatest  care  must  be  taken  to  go  well  beyond 
the  disease  and  into  bowel  that  has  a  normal  blood  sup- 
ply. If  after  dividing  the  bowel  an  abundant  flow  of 
arterial  blood  is  not  obtained  the  resection  should  be 
made  at  still  greater  distance  from  the  disease  where  the 
blood  supply  is  normal. 

If  the  bowel  is  merely  brought  into  the  wound  and 
drained,  the  contents  of  the  small  intestine  empty  freely 
on  the  skin  of  the  abdomen  and  a  marasmic  and  septic 
condition  is  often  initiated  which  practically  precludes 
any  further  operation  and  terminates  fatally.  If  drain- 
age is  considered  wise,  it  should  be  done  in  the  loop  of 
intestine  just  above  the  point  of  resection  by  means  of  a 
rubber  catheter  fixed  into  the  intestine,  after  the  method 
of  Witzel.  A  large,  soft  rubber  catheter  will  drain  off 
fluid  material  satisfactorily  and  will  give  exit  to  the  gas. 

In  doing  a  resection  care  must  be  taken  to  divide  and 
tie  the  mesentery  before  the  bowel  is  opened.  In  many 
techniques  the  bowel  is  first  opened  and  the  same  scis- 
sors or  knife  with  which  the  bowel  is  cut  also  divides 
the  mesentery.  This  infects  the  triangular  area  at  the 


OCCLUSION    OF    MESEXTERIC    BLOOD-VESSELS. 


mesenteric  border  where  the  layers  of  the  peritoneum 
separate  to  envelop  the  bowel.  This  area  is  rich  in 
lymphatics  and  small  blood-vessels  and  the  instrument 
which  has  become  septic  by  incising  the  intestinal  mucosa 
promptly  inoculates  this  area.  After  it  has  been  inocu- 
lated, closing  by  sutures  does  not  prevent  subsequent 
infection  here  and  breaking  down  of  the  stitches. 


Fig.  66. — Before  the  bowel  is  divided,  its  mesentery  is  cut  close  to  the  bowel  wall 
and  the  triangular  space,  caused  by  separation  of  the  layers  of  the  mesentery 
just  before  they  cover  the  bowel,  is  clamped  with  a  hemostat  and  ligatcd  with 
silk  or  linen.  Thi,s  area  is  composed  of  areolar  tissue  rich  in  blood-vessels 
and  lymphatics  which  absorb  quickly,  and  even  though  it  is  closed  after  it 
has  been  inoculated,  the  germs  are  merely  sealed  in  and  are  likely  to  cause 
breaking  down  of  the  union  at  this  point  later  on.  The  procedure  indicated 
in  the  cut  obviates  this  and  also  brings  together  the  peritoneum  at  this  point. 

In  order  to  obviate  this,  the  mesentery  must  be  cut 
close  to  the  bowel  and  this  area  clamped  and  tied;  after 
it  has  been  sealed  in  this  way  the  lumen  of  the  bowel  may 
be  opened  (Fig.  66).  The  bowel  is  then  divided  and  its 
ends  cleaned  with  moist  antiseptic  gauze.  The  first 
stitch  begins  in  the  end  of  the  bowel  at  the  operator's 
right  hand,  about  one-third  of  an  inch  from  the  mesen- 


206 


SURGERY    OF    THE    BLOOD-VESSELS. 


teric  border.  It  is  a  mattress  stitch  and  starts  from  the 
mucosa  of  the  right  bowel  penetrating  all  coats.  Then 
the  needle  is  carried  across  to  the  left  end  of  the  bowel 
and  penetrates  all  coats,  entering  on  the  peritoneal  sur- 
face and  emerging  from  the  mucosa.  It  comes  back  in 


Fig.  67. — The  first  stitch  starts  in  the  end  of  the  bowel  at  the  operator's  right  hand 
about  one-third  of  an  inch  from  the  mesenteric  border.  It  is  a  mattress  stitch 
and  penetrates  the  wall  of  the  right  bowel  from  within  out.  The  needle  is 
then  carried  across  to  the  left  end  of  the  bowel  and  penetrates  all  coats,  en- 
tering on  the  peritoneal  surface  and  emerging  from  the  mucosa.  It  comes 
back  in  the  reverse  direction,  entering  the  mucosa  and  emerging  on  the  peri- 
toneal surface,  then  enters  on  the  peritoneal  surface  of  the  right  bowel  and 
emerges  on  the  mucosa.  The  thread  is  tied,  leaving  an  end  about  four  inches 
long  which  is  grasped  in  hemostatic  forceps.  The  needle  is  then  passed  back 
and  forth  through  all  coats  of  the  bowel,  suturing  away  from  the  operator, 
and  making  a  continuous  mattress  stitch.  After  about  one-third  of  the  cir- 
cumference has  been  sutured,  the  needle  emerges  from  the  lumen  of  the  right 
end  of  the  bowel  and  is  then  thrust  through  all  walls  of  the  right  end  from 
within  out,  appearing  on  the  peritoneal  surface  of  the  right  end.  The  stitch 
is  then  continued  as  a  right-angled  suture  penetrating  all  coats  of  the  bowel. 

the  reverse  direction,  entering  the  mucosa  of  the  left 
bowel  and  emerging  on  the  peritoneal  surface,  entering 
the  peritoneal  surface  of  the  right  bowel  and  emerging 
from  the  mucosa.  The  thread  is  tied,  leaving  an  end 
about  four  inches  long  which  is  clamped  with  a  light 


OCCLUSION    OF    MESENTERIC    BLOOD-VESSELS.  2.0 1 

hemostatic  forceps.  The  needle  is  then  passed  back  and 
forth  through  all  coats  of  the  bowel,  suturing  away  from 
the  operator,  making  a  continuous  mattress  stitch.  Care 
must  be  taken  to  include  a  portion  of  the  mesentery  that 
has  been  tied,  else  it  will  slip  back  and  will  not  be  fas- 
tened by  the  suture.  Each  suture  must  be  very  snugly 


approximated.  After  about  one-third  of  the  circum- 
ference of  the  bowel  has  been  sutured,  the  needle  emerges 
from  the  lumen  of  the  right  end  of  the  bowel,  and  is  thrust 
through  all  walls  of  the  right  end,  appearing  on  the  peri- 
toneal surface  (Fig.  67).  The  stitch  is  continued  as  a 
right  angle  stitch  penetrating  all  coats  (Fig.  68).  Snug 
approximation  should  be  made  with  each  stitch  and  at 
about  every  third  or  fourth  stitch  a  back-stitch  should  be 


208 


SURGERY    OF    THE    BLOOD-VESSELS. 


taken  in  order  to  prevent  the  thread  being  drawn  too 
tightly,  and  so  diminishing  unduly  the  caliber  of  the 
bowel.  This  is  done  by  taking  two  consecutive  stitches 
on  the  same  side,  the  last  one  being  slightly  farther  back 
than  the  preceding  stitch.  It  is  very  important  to  have 
the  first  third  of  the  suture  line  that  unites  the  mesen- 
teric  border  drawn  tightly,  but  after  this  unless  the  back- 


Fig.  69. — The  suturing  has  been  completed,  the  last  stitch  being-  taken  in  the  left 
end  of  the  bowel  slightly  beyond  the  lowest  point  where  the  original  end  of 
the  thread  comes  out.  The  knot  should  be  snug  and  should  be  tied  parallel 
to  the  line  of  sutures  so  that  it  will  sink  in  easily.  The  ends  should  be  cut 
short  and  will  disappear  in  the  lumen. 

stitch  is  taken  at  intervals,  pulling  the  thread  may  di- 
minish the  lumen  so  much  as  to  produce  obstruction. 

The  suture  is  continued  toward  the  operator  and  is  car- 
ried a  short  distance,  about  a  stitch,  beyond  the  lowest 
point  where  the  original  thread  left  when  the  knot  was 
tied  comes  out.  This  last  stitch  is  in  the  left-hand  side 
of  the  bowel.  The  thread  is  then  tied  firmly  to  the  orig- 
inal end  that  is  grasped  in  the  hemostat.  The  knot  should 


OCCLUSION    OF    MESENTEEIC    BLOOD-VESSELS.  201) 


Fig.  70. — The  sigmoid  has  been  resected,  the  ileum  cut  across  near  the  ileo-cecal 
valve,  and  its  distal  end  closed  by  invagination.  The  ileum  has  been  sutured 
to  the  distal  portion  of  the  sigmoid,  end-to-end,  and  the  descending  colon  is 
drained  into  the  ileum  by  an  end-to-side  anastomosis.  In  this  way,  the  de- 
fect left  by  excising  the  sigmoid  is  bridged  over  by  transplanting  the  ileum, 
and  the  secretions  from  the  large  bowel  are  drained  into  the  ileum. 


210  SURGERY    OF    THE    BLOOD-VESSELS. 

be  tied  parallel  to  the  line  of  suturing  so  as  to  sink  in 
easily  and  should  be  tied  quite  snugly  (Fig.  69).  If  a 
back-stitch  has  been  taken  at  proper  intervals,  there  is 
no  danger  of  reducing  the  lumen  by  tying  the  knot  too 
tightly.  It  had  best  be  tied  three  times  and  then  cut 
short ;  the  ends  will  disappear  within  the  bowel. 

This  method  is  simple,  leaves  all  knots  within  the  bowel, 
and  there  should  be  no  leakage  when  it  is  properly  used. 
The  danger  of  obstruction  to  the  lumen  is  obviated  by 
placing  occasional  back-stitches  and  by  properly  approx- 
imating each  stitch  as  it  is  made.  The  thread  is  prac- 
tically all  buried,  leaving  almost  no  thread  exposed  on 
the  peritoneal  surface,  and  the  whole  suturing  can  be 
done  very  quickly.  All  of  these  features  are  important 
and  particularly  so  after  a  rather  extensive  operation 
such  as  transplantation  of  the  bowel  after  resection  of 
the  sigmoid. 

If  the  thrombosis  occurs  in  the  inferior  mesentery, 
whether  from  injury  or  from  volvulus,  rather  extensive 
gangrene  of  the  sigmoid  and  descending  colon  is  likely 
to  result.  After  such  an  extensive  excision  it  will  be 
impossible  to  unite  the  ends  of  the  bowel,  and  the  usual 
procedure  is  to  make  an  artificial  anus  or  else  to  excise 
the  remainder  of  the  large  bowel  and  do  an  ileo-sigmoidos- 
tomy,  which  greatly  prolongs  the  operation  and  is  often 
out  of  the  question  here.  An  artificial  anus  in  the  cecum 
can  be  made  without  the  dangers  that  would  attend  an 
opening  higher  up  in  the  small  intestine.  If  the  pa- 
tient's condition  warrants  it,  the  ileum  should  be  divided 
near  its  termination,  united  by  end-to-end  suture  to  the 
distal  part  of  the  sigmoid  or  rectum  by  the  technique  de- 
scribed above,  and  the  transversed  colon  drained  into  the 
ileum  higher  up  by  a  lateral  or,  better,  an  end-to-side  an- 
astomosis (Fig.  70). 


CHAPTER  XII. 
ANEURISMS. 

The  term  aneurism  is  applied  to  a  cavity  which  com- 
municates with  circulating  arterial  blood.  The  two  gen- 
eral classifications  of  aneurism  are  the  true  and  the  false. 
A  false  aneurism  is  formed  from  a  hematoma  and  is 
equivalent  to  the  later  stages  of  the  so-called  pulsating 
hematoma.  If  in  an  injury  to  an  artery,  blood  is  poured 
out  and  a  hematoma  forms  sufficient  to  prevent  further 
bleeding,  the  cavity  in  the  center  of  the  hematoma  may 
become  lined  with  endothelium  and  the  tissues  in  the 
neighborhood  form  a  connective  tissue  sac.  This  is  a 
typical  false  aneurism.  A  true  aneurism  is  not  a  tumor 
in  the  ordinarily  accepted  meaning,  for  a  tumor  is  new 
tissue  that  has  sprung  from  a  matrix  of  cells.  A  true 
aneurism  is  a  dilatation  of  a  previously  existing  vessel 
and  is  not  in  any  real  sense  new  tissue. 

Aneurisms  are  divided  into  (1)  congenital,  (2)  spon- 
taneous or  idiopathic,  (3)  traumatic,  (4)  embolic,  and 
(5)  aneurisms  by  erosion.  The  so-called  cirsoid  aneu- 
rism is  not  an  aneurism  but  a  true  tumor,  as  it  springs 
from  a  matrix  of  angioblasts  and  produces  vessels  where 
normally  they  do  not  occur.  Congenital  aneurisms  are 
exceedingly  rare  and  chiefly  occur  in  persistence  of  the 
ductus  arteriosus  of  the  fetus.  Idiopathic  aneurism  is 
due  to  disease  of  the  arterial  walls,  nearly  always  of  the 
middle  coat.  It  may  be  initiated  by  a  sudden  rise  of 
blood  pressure  or  a  local  trauma,  but  these  things  would 

not  in  a  normal  vessel  cause  an  aneurism.     Spots  in  the 

211 


212  SURGERY    OP    THE    BLOOD-VESSELS. 

middle  coat  become  soft  and  weakened  from  disease,  or 
considerable  areas  sometimes  may  be  similarly  affected. 
If  it  is  localized  to  a  small  area  a  sac  is  first  formed  but 
if  the  whole  artery  gives  way,  a  spindle-shaped  aneurism 
occurs.  Later,  these  aneurisms  may  alter  their  form,  so 
a  spindle-shape  becomes  sacculated  or  vice  versa.  If,  for 
instance,  an  aneurism  that  begins  spindle-shaped  has 
firm  support  on  one  side,  as  would  be  the  case  in  the 
popliteal  artery,  the  bone  and  solid  tissue  in  front  would 
eventually  cause  the  posterior  wall  to  give  way  more 
freely  and  an  aneurism  that  began  spindle-shaped  be- 
comes sacculated.  If  the  weakening  of  the  middle  coat, 
which  caused  a  sacculated  aneurism  extended  around  the 
artery,  a  spindle-shaped  or  cylindrical  aneurism  would 
probably  result.  If  blood  breaks  through  the  intima  it 
may  dissect  the  coats  of  the  vessel  for  some  distance  and 
return  to  the  main  artery  at  another  point.  This  is 
particularly  likely  to  occur  in  the  aorta,  and  sometimes 
this  new  channel  is  lined  with  endothelium.  The  idio- 
pathic  aneurisms  are  by  all  means  most  numerous. 
Traumatic  aneurisms  are  supposed  to  be  due  to  direct 
injury  of  the  arterial  wall  and  are  very  likely  to  be  false 
aneurisms,  or  arteriovenous  aneurisms. 

Various  parts  of  the  sac  occasionally  give  way  and 
one  aneurism  may  be  engrafted  upon  another,  so  pro- 
ducing a  multilocular  sac. 

Embolic  aneurisms  are  due  to  an  embolus,  which  may 
or  may  not  be  infectious.  The  embolus  may  consist  of  a 
foreign  body  that  has  lodged  in  some  portion  of  an  artery 
and  causes  dilatation  either  mechanically  or  from  infec- 
tion. 

Erosion  aneurisms  are  practically  abscesses  or  local- 
ized deposits  that  form  along  the  course  of  an  artery  and 
weaken  the  arterial  wall,  eventually  communicating  with 


ANEURISMS.  213 

the  artery.  These  should  be  classed  under  false  aneu- 
risms. A  true  aneurism  is  practically  always  of  spon- 
taneous type  and  has  one  or  more  coats  of  the  artery  in 
its  sac.  The  middle  coat  is  always  lacking  except  in  the 
very  beginning  of  the  aneurism  when  some  trace  of  the 
media  may  be  seen. 

The  sac  of  an  aneurism  may  be  cylindric,  fusiform,  or 
sacciform,  and  one  of  these  forms  may  change  into  the 
other  either  on  account  of  the  anatomical  surroundings, 
as  has  already  been  mentioned,  or  on  account  of  the  loca- 
tion near  a  joint,  or  from  the  change  of  direction  of  the 
blood  stream.  The  location  of  an  aneurism  has  a  great 
deal  to  do  with  its  shape.  Aneurisms  of  the  aorta,  where 
the  viscera  of  the  thorax  or  abdomen  offer  but  little  re- 
sistance, may  attain  large  size.  Aneurisms  developed  in 
dense  tissue  grow  in  the  direction  of  least  resistance. 
The  sac  of  an  aneurism  is  lined  with  endothelium,  and 
frequently  contains  an  old  white  blood  clot  that  has  been 
partly  or  fully  organized  and  may  practically  form  an- 
other layer  of  the  sac.  Sometimes  a  number  of  these 
clots  occurs.  It  was  formerly  thought  that  white  clots 
were  different  from  the  softer  or  red  clots,  but  there  is 
usually  a  gradual  transition  from  the  red  clot  to  the  white 
clot.  The  red  clot  becomes  partly  organized,  its 
coloring  matter  is  absorbed,  the  fibrin  contracts,  its  sub- 
stance is  penetrated  by  blood-vessels,  and  it  forms  a  dis- 
tinct layer. 

Occasionally,  but  not  often,  the  sac  is  completely  filled 
with  clots  which  organize  and  cure  the  aneurism.  Such 
an  occurrence  is  so  infrequent  as  to  be  counted  a  surgical 
curiosity.  The  tendency  of  an  aneurism  is  to  grow  until 
rupture  occurs  or  until  death  results  in  some  other  way. 
In  the  abdominal  aorta  three-fourths  of  the  aneurisms  re- 
sult fatally  by  rupture.  Death  may  also  be  caused  by 


214  SURGERY    OF    THE    BLOOD-VESSELS. 

pressure  upon  the  lungs  or  trachea,  by  infection  and 
sloughing  of  the  sac,  or  by  gangrene  in  the  extremities, 
but  the  most  usual  termination  is  by  rupture. 

The  direct  cause  of  the  vast  majority  of  aneurisms  is, 
as  has  already  been  stated,  a  disease  of  the  middle  coat 
of  the  artery.  This  form  of  arteriosclerosis  is  one  of 
the  handicaps  of  civilization.  No  lower  animal  has  aneu- 
rism except  the  horse  which  sometimes  has  a  form  of  em- 
bolic  aneurism  from  a  parasite,  strongylus  armatus.  In 
fact,  it  is  practically  impossible  to  produce  experiment- 
ally aneurisms  in  the  lower  animals  that  correspond  to 
the  idiopathic  aneurism  in  man.  Some  pathologists  have 
created  aneurisms  in  animals  by  the  injection  of  supra- 
renal extract  or  other  toxic  substances  that  cause  de- 
generation of  the  middle  arterial  coat.  This  has  been 
done  in  rabbits,  but  under  ordinary  conditions  the  idio- 
pathic aneurism  is  unknown  in  the  lower  animals.  The 
influence  of  civilization  is  best  shown  by  the  fact  that  in 
slavery  days  aneurisms  in  the  negroes  were  almost  un- 
known, whereas  now  it  is  four  times  more  frequent  in 
negroes  than  in  the  white  race.  More  than  seventy  per- 
cent of  aortic  aneurisms  are  due  to  syphilis.  Syphilis 
combined,  as  it  often  is,  with  alcoholic  excesses  and  some- 
times with  hard  manual  labor,  practically  constitutes  the 
sum  total  of  the  direct  causes  of  idiopathic  aneurisms. 
As  Osier  has  said,  Venus,  Bacchus,  and  Hercules  are  the 
etiologic  trinity  of  aneurisms.  Syphilis  and  alcohol 
cause  degeneration  of  the  middle  muscular  or  elastic  coat 
and  exertion  or  undue  pressure  from  any  cause  produces 
a  giving  away  at  this  point,  similar  to  what  the  automo- 
bilist  calls  a  blow-out. 

As  might  be  expected,  the  main  artery,  which  has  the 
chief  burden  of  blood  pressure  to  bear,  is  the  most  fre- 
quent seat  of  aneurism.  According  to  Matas  in  one  hun- 


ANEURISMS.  - 1  •") 

dred  and  seventy-two  cases  of  aneurism  compiled  by  I  lol- 
combe,  they  were  distributed  as  follows :  in  the  thoracic 
aorta,  seventy;  in  the  abdominal  aorta,  thirty-six;  popli- 
teal, twenty-one;  femoral,  ten;  innominate,  nine;  sub- 
clavian,  eight;  common  carotid,  five;  external  iliac,  two; 
brachial,  two;  axillary,  two;  and  one  each  in  the  verte- 
bral, ulnar,  radial,  celiac  axis,  splenic,  occipital,  and 
temporal  artery. 

It  is  interesting  to  note  that  after  the  aorta,  aneurisms 
of  the  popliteal  are  most  frequent.  This  is  due  not  to 
the  unusual  pressure  in  this  vessel,  but  to  the  trauma 
from  the  frequent  flexion  and  extension  of  the  knee. 

Aneurism  in  young  children  is  practically  unknown. 
It  occurs  most  often  between  forty  and  fifty  years  and  is 
not  infrequent  in  old  age.  As  we  would  expect,  it  is 
chiefly  a  disease  of  the  male  and  in  the  proportion  of 
about  two  to  one.  After  the  fifth  decade,  however,  it 
seems  to  occur  equally  in  both  sexes.  The  etiologic 
factors  that  have  already  been  mentioned  will  readily 
suggest  why  it  is  chiefly  a  disease  of  man.  The  size  of 
an  aneurism  depends  partly  upon  its  location.  An  aneu- 
rism may  attain  enormous  proportions  in  the  thorax  or 
abdomen,  whereas  in  the  brain  and  particularly  in  the 
region  of  the  fourth  ventricle,  a  very  small  aneurism  may 
be  fatal. 

Symptoms  and  Signs. 

Usually  an  aneurism  is  readily  recognized,  but  some- 
times when  numerous  clots  have  been  deposited  within 
the  sac  its  diagnosis  is  exceedingly  difficult.  Before  the 
advent  of  the  X-ray  a  mistake  was  by  no  means  rare. 
Such  surgeons  as  Dupuytren,  Esmarch,  Pirogoff,  and 
many  others  have  made  disastrous  errors  in  the  diagnosis 
of  this  condition,  which,  however,  would  hardly  be  justi- 


216  SURGERY    OF    THE    BLOOD-VESSELS. 

fiable  at  the  present  time.  The  history  of  the  case  is 
always  of  great  importance  and  should  he  carefully  taken 
wherever  there  is  a  possibility  of  aneurism.  A  history 
of  syphilis,  or  the  presence  of  a  positive  Wassermann,  in 
connection  with  any  growth  along  the  blood-vessels  would 
make  a  diagnosis  of  aneurism  very  much  more  probable. 
The  age  of  the  patient,  race,  sex  and  habits  are  also  sug- 
gestive. The  history  of  the  growth,  the  presence  of  pain, 
the  presence  or  absence  of  a  leukocytosis,  particularly  a 
high  count  of  polynuclear  white  cells,  may  serve  to  dif- 
ferentiate between  an  abscess  and  an  aneurism. 

The  physical  examination  to  be  made  depends  to  a 
large  extent  upon  the  location  of  the  aneurism.  If  in  the 
thoracic  aorta  it  attains  a  large  size  before  the  sac  can 
be  palpated.  Here,  however,  the  physical  signs  should 
give  some  indication,  for  there  is  dullness  on  percussion 
and  possibly  the  presence  of  a  thrill  that  may  be  felt. 
Bronchial  breathing,  shortness  of  breath,  visible  enlarge- 
ment of  the  veins  of  the  neck  and  arms,  sometimes  swell- 
ing of  the  arms  and  neck,  pain  referred  to  the  intercostal 
nerves,  hoarseness,  cough,  or  even  paralysis  of  the  left 
vocal  cords  caused  by  pressure  on  the  recurrent  laryn- 
geal,  disturbances  from  pressure  upon  sympathetic  nerves 
as  contraction  or  dilatation  of  the  pupil,  sometimes  diffi- 
culty in  swallowing  and  frequently  trachial  tugging  are 
the  chief  signs  and  symptoms  of  a  thoracic  aneurism. 
Trachial  tugging  is  best  brought  out  by  extending  the 
head  and  neck,  when  the  larynx  is  seen  to  be  pulled  upon 
by  the  trachea  at  each  beat  of  the  heart.  Probably  the 
most  important  diagnostic  aid  in  thoracic  aneurism  is 
the  X-ray.  The  refinement  of  modern  skiagraphy  can 
show  the  presence  of  a  thoracic  aneurism  of  even  small 
size  and  should  always  be  appealed  to  in  making  a  diag- 
nosis of  this  condition. 


ANEURISMS.  217 

The  signs  and  symptoms  of  aneurisms  in  other  por- 
tions of  the  body  depend  to  some  extent  upon  the  loca- 
tion. In  an  aneurism  situated  in  one  of  the  extremities 
or  in  the  neck  there  is  a  difference  in  the  pulsation  of 
the  artery  distal  to  the  aneurism  when  compared  with 
the  corresponding  artery  in  the  other  limb  or  on  the 
other  side  of  the  neck.  This  is  due  to  the  fact  that  a 
great  deal  of  the  pressure  in  the  blood  stream  is  taken 
up  in  the  aneurism  and  the  artery  distal  to  it  has  lower 
pressure  than  the  corresponding  artery  on  the  other  side 
of  the  body.  The  beat  is  usually  somewhat  delayed  for 
the  same  reason.  Frequently  the  pressure  of  the  aneu- 
rism on  the  veins  in  the  neighborhood  will  produce  edema 
or  swelling  distal  to  the  aneurism  and  also  enlargement 
of  the  veins.  Occasionally  the  venous  collateral  circula- 
tion is  made  evident  by  the  dilated  veins  under  the  skin. 
If,  however,  pressure  upon  the  vein  is  not  too  great 
there  is  but  slight  dilatation  of  the  superficial  veins  as 
the  venous  flow,  even  when  partially  obstructed,  can  re- 
turn the  diminished  arterial  supply  unless  the  pressure 
in  the  artery  is  so  interfered  with  by  the  aneurism  that 
the  blood  cannot  be  properly  forced  through  the  vein. 
Pressure  upon  nerves  often  causes  pain  and  sometimes 
muscle  spasm  and  trophic  disturbances.  There  may  even 
be  erosion  of  the  bone  which  can  be  demonstrated  by 
X-ray.  As  a  rule,  however,  aneurisms  in  the  extremities 
grow  in  the  direction  of  least  resistance  and  that  wall 
which  is  opposed  by  solid  bony  tissue  will  lie  supported 
and  the  aneurism  will  be  forced  to  enlarge  in  other  di- 
rections. Sometimes  infection  of  the  sac  occurs.  This 
seems  peculiarly  liable  to  happen  in  the  external  iliac  and 
upper  femoral  arteries  and  has  been  the  cause  of  many 
disastrous  mistakes.  The  inflammatory  thickening  of 
the  tissues  together  with  the  increased  coagulability  of 


218  SUKGERY    OF    THE    BLOOD-VESSELS. 

the  blood,  which  may  cause  deposit  of  clots  in  the  sac, 
frequently  obliterates  any  pulsation  that  normally  would 
be  present.  The  signs  of  inflammation  and  probably  the 
actual  presence  of  pus  may  lead  the  operator  to  believe 
there  are  several  pockets,  and  in  his  effort  to  be  thorough 
the  aneurism  may  be  opened.  With  the  history  of  the 
case  and  a  good  X-ray  picture,  such  mistakes  should  be 
very  infrequent  in  modern  times. 

The  physical,  local  signs  of  aneurism  are  expansile 
pulsation,  thrill,  and  bruit.  Pulsation  can  be  detected  by 
sight  and  by  palpation.  An  aneurism,  the  walls  of  which 
are  too  thick  for  pulsations  to  be  distinctly  expansile, 
should  be  distinguished  from  a  solid  tumor,  and  some- 
times from  an  inflammatory  mass  that  rests  upon  the  ar- 
tery and  transmits  pulsations.  The  character  of  the 
expansile  pulsation  can  usually  be  told  by  resting  two 
fingers  close  together  upon  the  enlargement  and  observ- 
ing that  they  are  not  only  lifted  up  but  that  they  are  to 
some  extent  separated  at  the  height  of  each  pulsation. 
A  more  accurate  way  of  determining  this  would  be  to 
mark  two  points  on  the  skin  over  the  enlargement  and. 
test  the  distance  between  them  with  calipers  during  sys- 
tole and  during  diastole. 

A  thrill  is  often  felt  by  palpation  with  the  fingers  or 
with  the  whole  hand.  It  is  not  so  marked  in  aneurisms 
as  in  arteriovenous  aneurisms.  Bruit  is  detected  by 
auscultation  and  is  heard  most  distinctly  over  the 
growth,  though  it  may  be  transmitted  along  the  course 
of  the  artery  for  some  distance.  This  is  not  due  to  vi- 
bration of  the  opening,  as  was  formerly  thought,  but  the 
sound  is  made  by  the  current  of  blood. 

Direct  pressure  on  an  aneurism  usually  diminishes  it, 
but  when  the  pressure  is  removed  the  aneurism  returns 
to  its  original  size.  All  of  the  characteristic  signs  are 


ANEURISMS. 

abolished  when  the  main  trunk  of  the  artery  between  the 
aneurism  and  the  heart  is  compressed. 

Treatment. 

The  treatment  of  aneurisms  is  divided  into  medical 
and  surgical.  Medical  treatment  consists  in  the  direc- 
tion of  diet,  and  personal  hygiene,  together  with  the  ad- 
ministration of  such  drugs  as  create  a  tendency  to  clot- 
ting in  the  sac.  This  is  supposed  to  be  obtained  by  di- 
minishing the  blood  pressure  on  the  one  hand,  and  by  in- 
creasing the  coagulability  of  the  blood  on  the  other. 

Medical  treatment  was  first  introduced  by  Valsalva 
and  Albertini  in  1728.  According  to  the  original  method 
it  consisted  of  absolute  physical  and  mental  rest,  and  re- 
peated bleedings.  In  this  manner  the  blood  pressure 
was  reduced  and  the  coagulability  of  the  blood  increased. 
Very  little  fluids  were  given  and  only  125  grams  of  food 
were  permitted  in  a  day.  This  treatment  has  been  made 
much  less  severe  and  now  ordinarily  consists  of  rest  in 
bed  and  a  light  diet,  without  bleeding,  together  with  the 
administration  of  such  drugs  as  increase  the  coagulabil- 
ity of  the  blood  or  lower  the  blood  pressure.  Iodide  of 
potash  appears  to  be  the  most  effective;  nitroglycerine 
and  the  nitrates  are  used.  Calcium  chloride  is  given  in 
doses  from  ten  to  twenty  grains  three  times  a  day 
with  the  idea  of  increasing  the  coagulability  of  the 
blood. 

The  injection  of  gelatin  has  received  a  great  deal  of 
attention.  Great  care  should  be  taken  in  sterilizing  the 
gelatin,  as  not  infrequently  cases  of  tetanus  have  been 
caused  by  imperfect  sterilization.  While  at  one  time  it 
was  extensively  used  in  thoracic  aneurisms,  it  is  now  but 
seldom  employed.  A  good  many  observers,  however, 
have  reported  very  striking  results.  Ennion  Gr.  Wil- 


220  SURGERY    OF    THE    BLOOD-VESSELS. 

Hams  l  reported  two  cases  of  thoracic  aneurism  in  which 
he  used  gelatin  with  temporary  benefit  in  one  case.  He 
recommends  injecting  fifty  cubic  centimeters  of  a  five  to 
ten  percent  solution  in  water,  great  care  being  taken  to 
sterilize  the  gelatin  thoroughly.  The  time  of  coagulation 
of  the  blood  decreased  from  two  and  a  half  minutes  be- 
fore injection  to  a  minute  and  a  half  after  injection  in  one 
of  his  cases.  Bollenstein,  in  1904,  reported  forty-six  per- 
cent of  favorable  results  in  126  cases.  These,  however, 
do  not  necessarily  mean  cures. 

The  action  of  gelatin  seems  to  be  chiefly  in  the  destruc- 
tion of  white  blood  cells,  thus  liberating  the  elements 
that  go  to  form  fibrin  ferment.  It  may  be  administered 
as  a  ten  percent  solution  in  ordinary  salt  solution  giving 
fifty  cubic  centimeters,  or  as  a  three  percent  solution  in 
Locke's  fluid,  injecting  250  cubic  centimeters  in  the  lum- 
bar or  glutial  regions  every  five  or  six  days  until  twenty 
injections  are  given.  This  may  be  continued  over  a  pe- 
riod of  several  months. 

The  diet  recommended  in  these  cases  is,  for  breakfast, 
two  ounces  of  bread  and  butter  and  two  ounces  of  milk; 
for  dinner,  three  ounces  of  meat,  two  ounces  of  bread  and 
potatoes,  and  four  ounces  of  water;  for  supper,  two 
ounces  of  bread  and  butter  and  two  ounces  of  tea.  This 
may  be  varied  to  some  extent,  particularly  in  the  line  of 
decreasing  meats  and  tea.  Milk  may  be  substituted  for 
meat. 

The  symptomatic  treatment  consists  in  the  administra- 
tion of  drugs  that  relieve  pain,  such  as  morphine  and 
atropine  or  codein,  or  such  remedies  as  aspirin.  Com- 
presses of  lead  water  and  opium  or  an  ice  bag  placed 
over  the  skin,  which  should  be  fully  protected,  often  af- 
ford some  relief. 


Old    Dominion    Medical   Journal,    August,    1903. 


ANEURISMS.  221 

Surgical  treatment  includes  various  methods,  such  as 
wiring,  electric  puncture,  direct  and  indirect  compres- 
sion, ligature,  incision,  obliteration  of  the  sac,  and  exci- 
sion of  the  sac  alone  or  combined  with  the  substitution 
of  a  segment  of  vein. 

We  will  first  consider  the  methods  particularly  appli- 
cable to  aneurisms  of  the  aorta  as  these  aneurisms  can- 
not be  reached  by  the  direct  attacks  employed  elsewhere. 
"Needling"  was  advised  by  McEwen  in  1890.  The 
method  is  quite  uncertain,  though  McEwen  reports  sat- 
isfactory results.  It  consists  of  the  introduction  into  the 
sac  of  a  long,  fine  needle  which  scratches  thoroughly  all 
of  the  lining  of  the  sac.  This  is  followed  by  the  disposi- 
tion of  fibrin  and  according  to  McEwen  the  fibrin  thrown 
down  after  needling  is  peculiarly  firm.  The  operation, 
however,  has  not  been  adopted  by  many  surgeons. 

The  introduction  of  wire  into  an  aneurism  was  first 
done  by  Moore,  of  London,  in  1864.  It  has  been  widely 
used,  particularly  in  connection  with  the  modification  by 
Corradi,  in  1879,  of  passing  a  galvanic  current  through 
the  wire.  Finney,  of  Baltimore,  has  had  very  favorable 
experience  with  it  and  reports  several  cases  much  bene- 
fited and  some  apparently  cured.  Finney  recommends 
the  wire  originally  proposed  by  Hunner,  which  consists 
of  a  silver  alloy  containing  seventy-five  parts  of  copper 
to  1,000  parts  of  silver.  This  wire  is  wound  tightly  on  a 
wooden  spool,  in  order  to  make  it  coil,  and  should  be  of 
such  size  as  will  readily  pass  through  the  ordinary  as- 
pirating needle.  The  needle  is  insulated  with  a  coat  of 
the  best  French  lacquer  to  within  a  short  distance  of  its 
point.  This  prevents  an  electrolytic  burn  that  might  be 
the  seat  of  a  subsequent  hemorrhage.  Under  local  anes- 
thetic the  needle  is  inserted  into  the  skin  which  is  drawn 
to  one  side  so  when  the  needle  is  removed  the  opening  in 


222  SURGERY    OF    THE    BLOOD-VESSELS. 

the  skin  is  not  opposite  the  opening  in  the  sac.  Finiiey 
uses  ten  feet  of  wire,  claiming  that  a  larger  amount  may 
prevent  the  contraction  of  the  clot  in  the  sac.  The  nee- 
dle is  inserted  slowly  until  arterial  blood  appears  in 
spurts  through  the  needle.  The  end  of  the  wire  should 
be  engaged  in  the  lumen  of  the  needle  before  the  needle 
is  inserted.  At  first  a  small  amount  of  blood  will  spurt 
around  the  wire.  The  wire  is  then  threaded  through 
into  the  aneurism,  care  being  taken  that  no  portion  of 
the  needle  that  is  not  protected  with  lacquer  comes  in 
contact  with  the  skin.  The  positive  pole  of  a  galvanic 
battery  should  then  be  connected  with  the  wire,  a  nega- 
tive pole  being  placed  at  the  patient's  back.  This  is  im- 
portant as  the  negative  pole  to  the  wire  will  cause  dis- 
organization of  the  clot  rather  than  hasten  its  formation. 
The  current,  according  to  Finney,  should  be  not  greater 
than  seventy-five  m.a.,  but  should  be  continued  at  least  an 
hour.  In  abdominal  aneurisms,  the  aneurism  should,  of 
course,  be  fully  exposed  and  the  viscera  packed  away. 
This  is  done  under  local  anesthesia.  After  the  current 
has  been  passed  at  least  an  hour  in  thoracic  aneurisms 
the  needle  is  slowly  removed,  twisting  it  somewhat  in 
order  to  withdraw  it  gradually.  The  skin  is  depressed 
around  the  wire  and  the  wire  cut  flush  with  the  skin. 
The  skin  is  then  pinched  up  and  the  end  of  the  wire  will 
disappear  under  the  skin.  If  the  skin  has  originally  been 
drawn  to  one  side,  there  is  no  direct  communication  be- 
tween the  hole  in  the  skin  and  that  in  the  sac. 

Aneurisms  of  the  aorta  should  first  be  carefully  stud- 
ied with  the  X-ray  before  being  subjected  to  wiring.  A 
diffuse  dilatation  or  a  spindle-shaped  aneurism  obviously 
cannot  be  treated  by  such  a  measure,  which  should  be 
reserved  for  the  distinctly  sacculated  type.  Attempts 
have  been  made  to  cure  aneurisms  of  the  abdominal  aorta 


ANEURISMS. 

by  ligature,  and  the  abdominal  aorta  lias  so  far  been 
ligated  for  various  causes,  chiefly  for  aneurism,  about 
twenty  times  with  fatal  result  in  each  case.  In  some  ab- 
dominal aneurisms  the  metal  band  introduced  by  Ilal- 
sted  seems  indicated.  By  this  means  the  circulation  can 
be  greatly  diminished  though  not  entirely  obliterated, 
and  after  collateral  circulation  has  been  sufficiently  es- 
tablished the  band  may  be  removed  and  a  ligature  ait- 
plied.  If,  however,  important  arteries,  such  as  the  renal 
or  the  coeliac  axis,  arise  from  a  prominent  portion  of  the 
sac  the  case  would  seem  utterly  hopeless,  as  any  method 
that  obliterates  the  sac  would,  of  course,  occlude  these 
arteries  with  the  necessity  of  a  fatal  result. 

In  the  treatment  of  aneurisms  of  the  extremities  it  is 
important  to  develop  the  collateral  circulation  to  as  great 
an  extent  as  possible  before  any  attempt  is  made  to  ex- 
cise the  aneurism  or  to  close  the  sac.  This  may  be  done 
by  hot  packs  around  the  limb  several  times  a  day,  ex- 
tending over  a  period  of  a  half  to  one  hour  at  a  time. 
Digital  pressure  on  the  artery  or  pressure  by  a  special 
apparatus  may  also  be  used.  The  circulation  should  be 
tested,  as  suggested  by  Matas,  by  applying  a  firm  Es- 
march  bandage  from  the  extremity  of  the  limb  to  the 
trunk.  The  main  artery  is  then  compressed,  the  Es- 
march  removed,  and  note  made  of  the  returning  circu- 
lation which  is  carried  on  collaterally.  In  the  leg  a 
hyperemic  flush  extends  quickly  to  the  knee,  but  may 
go  much  more  slowly  or  not  at  all  to  the  foot.  If  the 
flush  does  not  reach  the  ankle,  operation  should  be  post- 
poned and  treatment  with  hot  packs  or  local  compression 
of  the  artery  is  instituted  until  collateral  circulation  has 
been  satisfactorily  established.  The  most  serious  objec- 
tion to  this  method  of  testing  is  that  it  is  inapplicable  in 
negroes  or  in  people  with  a  very  dark  skin. 


224  SURGERY    OF    THE    BLOOD-YESSKLS. 

A  method  of  treatment  in  many  instances  and  a  most 
satisfactory  means  of  developing  collateral  circulation 
in  all  cases  is  the  use  of  a  metal  band,  first  devised  by  W. 
S.  Halsted.  The  original  Halsted  band  has  been  further 
modified  by  Matas  and  by  Halsted  and  in  its  simplest 
form  consists  of  a  small  band  of  aluminum,  about  one- 
fourth  of  an  inch  wide,  which  can  be  rolled  around  the 
artery  with  the  fingers.  Halsted  originally  devised  a 
special  instrument  for  this.  The  band  is  not  rolled 
tightly  enough  to  occlude  the  artery  but  merely  to  an  ex- 
tent that  will  reduce  its  circulation  to  a  minimum.  In 
this  manner  collateral  circulation  is  developed,  while  at 
the  same  time  there  is  a  small  current  through  the  main 
artery.  After  a  week  or  two  the  band  is  removed  and 
the  artery  either  occluded  by  a  tight  ligature  or  the  an- 
eurism obliterated  by  the  operation  of  Matas,  with  but 
little  danger  of  gangrene. 

Mayetti 2  describes  a  method  of  occluding  large  vessels 
by  strips  of  fascia  or  tendon  instead  of  metal  bands. 
The  fascia  is  taken  from  the  animal  or  individual  and 
constitutes  an  autograft.  Mayetti  recommends  fascia 
lata.  A  strip  is  placed  around  the  vessel  and  fastened 
with  a  silk  suture.  In  his  experimental  work,  the  artery 
could  be  reduced  to  one-third  of  its  natural  size  without 
signs  of  thrombosis. 

Matas  and  Allen  in  some  excellent  experimental  work 
demonstrated  the  feasibility  of  partial  obliteration  of  the 
aorta  in  dogs.  The  results  of  their  experiments  were 
read  before  the  American  Surgical  Association  in  May, 
1913,  (Annals  of  Surgery,  September,  1913).  They  show 
that  the  aorta,  if  healthy,  can  be  partially  occluded  by  in- 
folding it  with  layers  of  sutures.  This,  of  course,  cannot 
be  done  except  in  healthy  blood-vessels  which  unfortu- 

2  Policlinico,    Rome,   January    12,    1913. 


ANEURISMS. 

nately  is  the  exception  rather  than  the  rule  near  aneu- 
risms. 

Scalone 3  gives  a  method  for  partially  obliterating1 
blood-vessels  by  placing  sutures  with  a  curved  needle 
through  the  superficial  layers  of  the  blood-vessel  in  such 
a  manner  that  the  vessel  is  infolded  just  as  the  pylorus  is 
sometimes  infolded.  The  external  tissues  are  brought 
firmly  around  the  vessel  to  maintain  and  support  the  ob- 
struction. 

Compression  is  recognized  as  one  of  the  oldest  methods 
of  treating  aneurisms.  While  various  appliances  have 
been  used  they  have  not  been  quite  so  satisfactory  as 
digital  compression  properly  applied.  It  requires  a 
number  of  assistants  who  can  relieve  each  other  from 
time  to  time.  The  skin  where  pressure  is  to  be  made  is 
covered  with  French  chalk.  Each  assistant  is  instructed 
as  to  the  amount  of  pressure  necessary,  the  direction  in 
which  it  must  be  made,  and  the  manner  of  changing  from 
one  assistant  to  another,  so  at  no  time  during  the  treat- 
ment is  the  artery  without  compression  at  or  about  the 
same  point.  The  femoral  artery  below  Poupart's  liga- 
ment is  the  most  favorable  location  for  digital  compres- 
sion. Each  sitting  lasts  four  hours.  Sometimes  one  sit- 
ting will  result  in  a  cure,  but  usually  ten  or  even  twenty 
sittings  are  necessary.  This  method  is  unsatisfactory 
and  uncertain  in  comparison  with  modern  methods  and 
is  by  no  means  free  from  danger  of  gangrene. 

The  elastic  compression  of  Eeid  consists  of  bandaging 
the  limb  by  means  of  an  elastic  bandage  up  to  the  aneu- 
rism and  then  skipping  the  aneurism,  but  bandaging  the 
limb  above  it.  In  this  way  the  blood  is  shut  off  above 
and  below  the  aneurism  and  clotting  is  often  produced. 
The  bandage,  however,  should  not  be  left  on  longer  than 

3  Policlinico,    September,    1913. 


226  SURGERY    OF    THE    BLOOD-VESSELS. 

an  hour  and  a  half  and  in  elderly  people  half  this  time  is 
much  safer.  According  to  Delbet,  this  treatment  leads 
to  gangrene  twice  as  often  as  digital  compression. 

Extreme  flexion  has  been  suggested  by  a  number  of 
surgeons,  but  is  often  called  the  method  of  Hart.  It  is 
applicable  in  the  treatment  of  aneurisms  developing  in 
the  popliteal  region,  in  the  groin,  or  in  the  elbow.  It 
consists  of  forced  flexion  which  must  be  maintained 
about  fourteen  days.  It  is  exceedingly  painful  and  cures 
only  about  one-third  of  the  cases. 

The  classical  methods  of  using  the  ligature  for4  the 
cure  of  aneurism  have  been  long  established.  The  op- 
eration of  Antyllus  has  been  practiced  since  the  second 
century  of  the  Christian  era,  and  has  on  the  whole  given 
exceedingly  satisfactory  results.  It  consists  of  ligating 
the  artery  close  to  the  aneurism,  both  centrally  and  dis- 
tally,  and  then  incising  the  sac  (Fig.  71).  In  preanti- 
septic  days  the  suppuration  following  this  method  made 
the  mortality  high,  but  in  spite  of  that  the  percentage  of 
cures  has  been  gratifying. 

Anel's  method,  first  used  in  1710,  is  ligating  the  artery 
centrally  but  as  close  as  possible  to  the  sac.  In  preanti- 
septic  days  where  suppuration  was  a  rule,  secondary 
hemorrhage  was  frequent.  It  was  thought  this  was 
partly  due  to  the  fact  that  the  artery  near  the  sac  was 
very  likely  to  be  diseased;  so  John  Hunter  established 
a  new  principle  of  ligating,  in  1785,  by  applying  the  liga- 
ture centrally,  but  at  some  distance  from  the  aneurism. 
In  this  method  branches  are  given  off  from  the  main  ar- 
tery between  the  ligature  and  the  aneurism.  It  is  still 
used  to  some  extent  but  has  many  disadvantages.  First 
of  all,  it  assumes  that  the  artery  is  less  diseased  at  a  dis- 
tance from  the  aneurism  than  close  to  it.  This  is  by  no 
means  always  true.  Secondly,  the  liability  to  gangrene 


ANEURISMS. 


227 


is  increased,  because  if  the  sac  is  occluded  by  a  clot  there 
will  be  two  obstructions  to  the  current  instead  of  one,  the 
obstruction  at  the  site  of  ligature  and  another  farther 


Brasdor. 


Warirop  . 


Fig.  71. — Diagram  illustrating  the  various  methods  of  ligation  for  aneurisms. 

down  where  the  aneurism  is  closed  by  clots.  Then  the 
collateral  circulation  between  the  ligature  and  the  sac  is 
greatly  diminished  and  the  blood  has  to  pass  through  two 
sets  of  collateral  branches,  one  from  above  the  ligature 


SURGERY    OP    THE    BLOOD-VESSELS. 

to  the  vessels  between  the  ligature  and  the  aneurism  and 
one  from  this  last  set  to  the  vesesls  below  the  aneurism, 
in  order  to  maintain  the  nutrition  of  the  limb.  If,  how- 
ever, the  collateral  circulation  is  free,  the  aneurism  may 
not  be  sufficiently  occluded  by  clots  and  no  cure  will  re- 
sult. With  modern  technique  and  absorbable  ligatures 
the  operation  of  Anel  is  far  superior  to  that  of  Hunter. 
Brasdor  instituted  the  method  of  distal  ligation  in 
1798,  ligating  distally  the  main  trunk.  Wardrop,  in 
1825,  applied  ligatures  distally  to  one  or  two  of  the  main 
branches  of  the  artery.  This  was  used  in  aneurisms  of 
the  innominate  where  the  carotid  artery  was  often  tied. 
The  application  of  a  ligature  immediately  above  and  be- 
low without  opening  the  sac  is  called  Pasquin's  method 
and  was  first  applied  in  1812. 

Ligation  on  each  end  and  close  to  the  aneurism  with 
extirpation  of  the  sac  has  been  known  as  the  operation 
of  Purmann,  who  used  it  in  16.80.  This  method  has  been 
recently  very  extensively  employed  on  the  continent.  It 
is  necessary  to  have  complete  hemostasis  either  by  the 
tourniquet,  or  by  clamping,  or  by  temporary  ligatures. 
Often  large  collateral  vessels  open  into  the  sac,  so  a  cen- 
tral ligature  may  not  completely  control  the  hemorrhage. 
It  is  also  important  to  preserve  the  vein  in  extirpating 
the  sac,  for  if  the  vein  is  injured  or  ligated,  gangrene  is 
much  more  likely  to  occur.  Bleeding  should  be  con- 
trolled by  sutures,  which  do  not  go  deeper  than  neces- 
sary, as  packing  if  depended  upon  to  stop  bleeding  may 
also  interfere  with  the  collateral  circulation. 

Gangrene  occurs  in  mass  or  in  patches  merely  involv- 
ing small  localized  areas.  It  is  particularly  important 
to  follow  the  usual  after-treatment,  to  stimulate  the  heart 
by  drugs  and  by  the  introduction  of  salt  solution  by  rec- 
tum. The  whole  limb  should  be  well  wrapped  in  cotton 


ANEURISMS.  -'20 

and  moderately  elevated  in  order  to  secure  venous  drain- 
age, but  not  too  much  elevated  as  this  might  interfere 
with  the  arterial  circulation.  Hot  air  ovens  may  be  used. 
After  the  wound  has  begun  healing,  hot  baths  and  mas- 
sage with  active  and  passive  motion  are  instituted. 

Ligation  with  extirpation  of  the  sac  compares  very 
favorably  in  results  with  simple  ligature,  as  it  has  a  some- 
what lower  mortality  in  a  large  number  of  cases  than  the 
Hunterian  method  of  ligation,  and  the  dangers  of  gan- 
grene are  about  the  same. 

The  greatest  improvement  in  the  treatment  of  aneu- 
risms in  modern  times  is  the  operation  of  Matas,  which 
was  first  performed  by  him  in  1888,  on  a  brachial  aneu- 
rism that  had  not  been  cured  by  either  proximal  or  dis- 
tal ligature.  The  operation  is  subdivided  into  three  dif- 
ferent types,  though  the  principle  is  the  same  in  each. 
The  fact  that  extirpation  of  the  sac,  and  that  the  Syme 
operation  in  which  the  artery  is  ligated  within  the  sac, 
is  followed  by  a  comparatively  low  mortality  and  a  high 
rate  of  cure  makes  it  quite  evident  that  the  nearer  the 
ligature  is  placed  toward  the  sac,  other  things  being- 
equal,  the  better  the  results  will  be.  The  objections  to 
extirpation  are  obvious.  The  operation  is  not  only  dif- 
ficult and  involves  the  enucleation  of  considerable  tissue, 
but  there  is  a  likelihood  of  injury  to  the  veins  or  nerves, 
and,  most  important  of  all,  the  tissues  enucleated  often 
carry  collateral  vessels  that  are  highly  important. 

The  three  types  of  the  operation  of  Matas  are  oblitera- 
tive  endo-aneurismorrhaphy,  restorative  endo-aneuris- 
morrhaphy,  and  reconstructive  endo-aneurismorrhaphy 
(Fig.  72).  The  obliterative  type  may  be  used  in  any 
form  of  aneurism,  but  it  was  particularly  designed  for 
cases  in  which  there  are  two  openings  in  the  sac  some 
distance  apart,  or  when  the  sac  is  peculiarly  friable. 


230  SUEGERY    OF    THE    BLOOD-VESSELS. 

Hemostasis  is  obtained  by  a  tourniquet  if  possible,  or 
if  this  is  impracticable  by  ("rile,  Matas  or  the  author's 
clamps  on  the  artery  and  its  main  branches  both  above 
and  below  the  sac.  The  sac  should  not  be  dissected  out, 
so  wherever  a  tourniquet  can  be  used  instead  of  a  clamp 
it  should  always  be  preferred.  By  bearing  in  mind  the 
principle  on  which  the  operation  is  founded — conserving 
every  possible  collateral  branch  in  the  sac  and  surround- 
ing tissues — the  operation  can  be  carried  out  more  intelli- 
gently. After  the  tourniquet  has  been  applied  an  ample 
incision  is  made  through  the  skin  over  the  aneurism.  If 
it  is  impossible  to  place  the  tourniquet,  the  vessel  is  ex- 
posed centrally  and  peripherally  a  few  inches  from  the 
aneurism,  and  clamps  applied,  as  mentioned  above.  The 
sac  is  then  opened  without  separating  it  from  the  sur- 
rounding tissue  and  clots  are  thoroughly  removed.  A 
suture  of  chromic  or  tanned  catgut  in  a  small,  round, 
curved  needle  is  passed  around  the  openings  of  the  artery 
taking  care  to  tie  the  openings  snugly  but  not  using  too 
much  force  as  the  suture  may  cut  out.  The  sac  is  searched 
for  other  openings  of  collateral  arteries  or  branches  and 
these  are  also  closed.  Then  the  sac  is  obliterated  by 
rows  of  sutures  of  chromic  or  tanned  catgut,  the  first  row 
running  preferably  from  one  arterial  opening  to  another. 
After  this  has  been  finished  another  row  is  placed.  In 
intraperitoneal  aneurisms  the  peritoneum  is  sutured  so 
as  to  cover  the  raw  surface.  The  manner  of  treating  the 
sac  after  the  two  tiers  of  obliterative  sutures  have  been 
placed  depends  largely  upon  the  condition  of  the  sac  and 
must  of  necessity  be  left  to  the  judgment  of  the  surgeon, 
as  in  plastic  work.  The  essential  features  are  to  close  the 
arterial  openings  into  the  sac  and  to  place  at  least  two 
rows  of  continuous  chromic  or  tanned  catgut,  obliterat- 
ing the  sac  as  far  as  possible  from  one  of  the  main  arte- 


ANEURISMS. 


231 


Fig.  72. — Rndo  -  aneurismorrhaphy. 
(A)  The  apertures  in  the 
aneurismal  sac  with  sutures 
inserted,  some  of  which  are 
tied.  (B)The  second  layer  of 
Futures  is  being  placed.  (C) 
Mattress  sutures  are  passed 
partly  through  the  skin  for 
further  closure  of  the  sac. 
(D)  Cross-section  of  obliterative 
endo  -  aneurismorrhaphy.  (E) 
reconstructive  en  do-aneurism 
morrhaphy  with  sutures  placed 
but  not  tied  and  catheter  in 
the  artery.  (F)  Catheter  be- 
ing removed  just  before  sutures 
are  tied.  (G)  Cross-section  of 
reconstructive  endo-aneurism. 
(After  Matas.) 


232  SURGERY    OF    THE    BLOOD-VESSELS. 

rial  openings  to  the  other.  After  this,  the  recesses  of 
the  sac  are  folded  upon  themselves  if  possible,  or  sutures 
are  carried  through  a  double  thickness  of  the  sac  and 
tied  in  the  margin  of  the  wound,  or  else  brought  out 
through  the  skin  (Fig.  72).  All  dead  spaces  should  be 
obliterated  and  the  wound  closed  without  drainage.  The 
blood  current  is  gradually  turned  on  before  the  skin  is 
sutured  and  the  infolded  sac  is  pressed  upon.  Usually 
but  little  if  any  oozing  occurs,  though  if  it  is  marked  the 
tourniquet  should  be  reapplied  and  the  leak  stopped  by 
additional  sutures.  The  smooth  membrane  lining  the  in- 
side of  the  sac  is  vascular  endothelium  and  requires  no 
freshening  or  injury  to  heal,  but  merely  snug  approxi- 
mation just  as  in  peritoneum. 

Restorative  endo-aneurismorrhaphy  is  applicable 
when  the  sac  is  tough  and  resistant  and  when  there  is 
only  one  opening.  In  other  words,  when  the  aneurism 
springs  from  one  side  of  the  artery  and  the  whole  of  the 
artery's  circumference  is  not  involved.  This  does  not 
occur  very  frequently.  In  such  cases  the  opening  is  su- 
tured either  by  surrounding  it  with  a  purse-string  suture 
or  by  whipping  it  over  with  a  continuous  stitch.  The 
rest  of  the  procedure  is  identical  with  the  obliterative 
method. 

Reconstructive  endo-aneurismorrhaphy  is  recom- 
mended by  Matas  in  cases  in  which  the  two  openings  are 
close  together,  where  there  is  but  little  atheroma,  and 
where  the  sac  is  tough  and  holds  sutures  well.  The  sac 
is  cleaned  of  clots  and  washed  out  with  salt  solution  and 
the  region  of  the  two  openings  is  anointed  with  white 
vaseline.  Matas  recommends  that  a  soft  rubber  cathe- 
ter well  anointed  with  vaseline  and  which  fits  snugly  into 
the  arterial  openings  be  inserted  and  interrupted  sutures 
of  chromic  catgut  be  placed  at  close  intervals  over  the 


ANEURISMS.  233 

catheter.  After  the  sutures  have  been  placed  the  cathe- 
ter is  withdrawn  and  the  sutures  tied  snugly.  The  rest 
of  the  sac  is  obliterated  as  in  the  other  methods. 

In  all  of  these  methods  care  should  be  taken  not  to 
take  a  deeper  bite  with  the  sutures  than  is  necessary  to 
secure  a  firm  hold.  The  needle  may  wound  the  accom- 
panying vein  or  nerve,  or  if  inserted  too  deeply,  may  oc- 
clude some  collateral  vessel. 

It  is  doubtful  if  reconstructive  endo-aneurismorrha- 
phy  does  not  sooner  or  later  become  obliterative.  The 
fact  that  in  several  instances  thrombi  formed  after  the 
reconstructive  operation  which  later  were  dislodged  and 
acted  as  emboli,  is  also  a  serious  objection  to  this  method. 
In  the  light  of  modern  blood-vessel  suturing,  we  can 
hardly  expect  the  reconstructed  artery  to  remain  patent. 
In  experimental  work  under  the  best  conditions  with 
comparatively  healthy  blood-vessels  and  using  the  finest 
sutures  of  silk  and  the  finest  needles,  it  is  impossible  to 
avoid  obliteration  in  a  considerable  number  of  cases  even 
after  some  experience  in  this  work.  This  being  the  case, 
we  can  hardly  expect  suturing  with  comparatively  coarse 
needles  and  catgut  in  tissue  that  is  diseased  to  reproduce 
a  permanently  patent  artery.  If  there  is  merely  a  small 
opening  the  restorative  method  may  be  indicated,  but 
the  eventual  result  will  probably  be  better  if  the  oblitera- 
tive method  is  always  used  instead  of  the  reconstructive 
type.  The  only  advantage  in  the  reconstructive  opera- 
tion is  the  fact  that  for  a  short  time  blood  flows  through 
its  natural  channel  and  the  consequent  strain  upon  col- 
lateral circulation  will  not  be  so  great.  This  advantage, 
however,  seems  offset  by  thet  dangers  of  sudden  emboli 
from  the  breaking  loose  of  the  thrombus,  by  the  fact  that 
sooner  or  later  the  channel  in  all  probability  becomes  ob- 
literated, and  by  the  further  fact  that  recurrences  are 


234  SURGERY    OF    THE    BLOOD-VESSELS. 

much  more  common  after  the  reconstructive  than  after 
the  obliterative  method. 

Matas  has  collected  statistics  which  prove  beyond 
doubt  that  wherever  endo-aneurismorrhaphy  can  be  ap- 
plied it  is  far  more  satisfactory  than  either  ligature  or 
extirpation;  not  only  is  the  mortality  rate  less  but  gan- 
grene is  exceedingly  rare. 

Extirpation  of  aneurisms  has  been  done  in  a  few  in- 
stances with  direct  suture  of  the  artery  by  the  end-to- 
end  method.  This  is  only  applicable  where  the  site  of 
the  aneurism  involves  a  very  short  section  of  the  artery 
and  where  the  ends  of  the  artery  are  comparatively 
healthy.  It  has  been  done  by  Lexer,  Stich,  and  Ender- 
len  in  popliteal  aneurisms.  The  limb  is  flexed  and  kept 
in  this  position  for  several  weeks  by  plaster  of  Paris. 
After  the  sixth  week  the  knee  may  be  gradually  extended. 
This  method  has,  of  course,  a  very  limited  application. 

The  ideal  treatment  of  aneurism  is  to  excise  the  sac 
and  at  the  same  time  to  restore  the  arterial  channel. 
This  is  accomplished  by  substituting  a  segment  of  vein. 
The  vein  that  accompanies  the  artery  has  been  used, 
though  it  would  be  much  better  to  utilize  some  other  vein. 
Obviously  when  the  direct  circulation  is  deficient  on  ac- 
count of  the  aneurism  and  collateral  circulation  is  poor, 
closing  the  main  artery  by  ligature  or  obliteration  of  the 
sac — even  by  the  excellent  method  of  Matas — is  fraught 
with  great  danger  and  the  indications  are  if  possible  to 
reestablish  the  circulation  by  the  ideal  method.  In 
a  diseased  artery,  arterial  sutures  would  not  seem  to 
be  satisfactory,  and  it  is  certainly  more  desirable  to  su- 
ture healthy  arteries  in  traumatic  aneurisms  than  the 
diseased  vessels  of  spontaneous  aneurisms.  However, 
the  brilliant  case  of  Lexer,  already  referred  to  above, 
in  which  he  excised  an  aneurism  involving  a  portion 


ANEURISMS. 

of  the  external  iliac  and  femoral  arteries  and  sutured 
into  the  defect  a  segment  of  the  saphenous  vein  with  per- 
fect success,  shows  the  great  possibilities  of  this  opera- 
tion. 

If  success  is  to  be  attained  in  suturing  diseased  arter- 
ies the  best  possible  technique  should  be  used.  As  already 
pointed  out,  it  is  not  likely  that  reconstructive  endo-aueu- 
rismorrhaphy  in  which  comparatively  coarse  needles  and 
catgut  are  used,  will  result  in  a  permanently  open  chan- 
nel. Certainly  in  experimental  work  such  technique 
would  invariably  be  followed  by  thrombosis  even  in 
healthy  arteries,  and  in  diseased  arteries  we  have  no 
right  to  expect  better  results.  It  is  practically  impossi- 
ble, however,  to  use  the  technique  of  arterial  suturing 
in  the  bottom  of  a  sac  where  the  tension  on  the  stitches 
must  be  considerable,  but  after  the  sac  is  excised  a  seg- 
ment of  vein  can  be  sutured  into  the  ends  of  the  artery 
with  the  regular  technique  for  end-to-end  suture.  While 
there  is  some  danger  of  the  segment  becoming  occluded 
by  thrombus,  it  would  seem  for  the  reasons  mentioned 
and  particularly  in  the  light  of  Lexer's  case  that  if  it  is 
necessary  to  reestablish  the  current  of  the  blood,  it 
should  be  done  not  by  the  reconstructive  method  of 
Matas,  but  by  excision  of  the  sac  and  suturing  into 
the  defect  a  segment  of  vein.  Reversing  the  circulation 
and  then  excising  the  aneurism  has  also  been  tried.  This 
has  none  of  the  advantages  of  transplantaion  of  a  vein. 

Treatment  of  Aneurism  of  Special  Arteries. 

Aneurisms  of  the  thoracic  aorta  are  by  far  the  most 
frequent  kind  of  aneurisms,  which  would  naturally  be  ex- 
pected from  the  strain  to  which  this  great  vessel  is  sub- 
ject. The  proper  treatment  is  the  medical  treatment 
that  has  already  been  outlined,  though  in  sacculated  tho- 


236  SURGERY    OF    THE    BLOOD-VESSELS. 

racic  aneurisms  the  Moore-Corradi  method  may  be  used. 
The  technique  as  employed  by  Finney  is  probably  the 
most  satisfactory  (page  221).  A  thorough  examination 
by  X-ray  should  be  done  before  this  operation  is  at- 
tempted. The  average  course  of  a  thoracic  aneurism  is 
a  little  more  than  a  year.  There  has  been  one  effort  to 
cure  a  thoracic  aneurism  by  ligating  the  aorta.  This 
was  done  by  Guinard,  of  Paris,  in  1904,  the  chest  being- 
opened  posteriorly  by  an  osteoplastic  flap  and  a  ligature 
placed  on  the  thoracic  aorta  just  below  the  end  of  the 
arch.  When  the  ligature  was  tightened,  pulsation  in  the 
femoral  artery  stopped  and  the  lower  part  of  the  body 
became  pale  and  cold,  but  in  a  few  minutes  the  circula- 
tion was  reestablished  through  the  intercostal  and  other 
vessels.  However,  the  blood  pressure  through  collat- 
eral circulation  was  not  sufficient  for  the  renal  arteries 
and  the  patient  died. 

Aneurisms  of  the  abdominal  aorta  are  scarcely  amena- 
ble to  other  direct  treatment  than  the  Moore-Corradi 
method.  If  the  aneurism  is  above  the  renal  arteries  or 
involves  the  mesenteric,  its  obliteration  will  necessarily 
result  fatally  on  account  of  interference  with  the  func- 
tion of  the  kidneys  or  from  gangrene  of  the  intestines. 
Below  the  inferior  mesenteric  artery,  the  outlook  seems 
more  hopeful,  but  the  results  are  practically  equally  as 
disastrous.  Of  about  twenty  cases  of  ligature  of  the 
abdominal  aorta  none  has  been  successful.  The  strain 
thrown  upon  the  heart  by  the  increased  blood  pressure 
after  such  a  ligature  is  enormous  and  this  high  pressure 
and  a  competent  heart  are  essential  to  the  proper  estab- 
lishment of  collateral  circulation.  Most  of  these  patients 
have  hearts  that  are  far  from  competent  and  even  in 
healthy  animals,  ligation  of  the  abdominal  aorta  usually 
results  in  a  cardiac  death.  In  a  case  of  Keen's  the  ab- 


ANEURISMS.  23 1 

dominal  aorta  was  ligated  and  the  patient  lived  until  the 
forty-eighth  day.  Even  if  the  heart  should  survive  the 
strain,  which  it  does  not  do  in  the  vast  majority  of  eases, 
there  is  still  the  risk  of  hemorrhage  and  the  possibility 
of  sepsis  and  shock.  The  iliac  arteries  have  been  ligated 
for  abdominal  aneurism,  following  the  principle  of  Bras- 
dor  and  Wardrop,  but  this  too  has  proved  fatal.  Vari- 
ous methods  of  compression  have  been  advocated  and 
even  endo-aneurismorrhaphy  has  been  tried,  but  unsuc- 
cessfully. The  aluminum  band  of  Halsted  which  would 
produce  a  partial  but  not  a  complete  occlusion  of  the 
aorta  seems  to  offer  the  most  satisfactory  method  of 
treatment,  if  wiring  and  galvanism  are  not  indicated. 
Various  problems,  particularly  the  strain  upon  the  heart, 
render  treatment  of  aneurism  of  the  aorta  a  very  unsat- 
isfactory procedure.  Experimentally,  a  portion  of  the 
abdominal  aorta  has  been  resected  and  a  tube  successfully 
sutured  into  the  defect  (page  73). 

Aneurisms  of  the  innominate  seem  to  offer  a  field  for 
the  Moore-Corradi  method,  though  they  have  been 
treated  successfully  by  ligature.  Apparently  the  best 
operation  is  distal  ligation  after  Wardrop  or  Brasdor. 
Ligation  of  the  right  common  carotid  and  the  right  sub- 
clavian  is  done  during  the  same  operation,  tying  the  caro- 
tid first  to  avoid  the  possibility  of  a  cerebral  embolus. 

Aneurisms  of  the  external  carotid  are  quite  rare,  but 
occasionally  occur.  Treatment  by  ligature,  placing  the 
ligature  as.  far  as  possible  from  the  bifurcation  of  the 
common  carotid,  may  be  employed.  The  injection  into 
the  external  carotid  of  boiling  water  after  the  sugges- 
tion of  Wyeth  might  be  indicated,  as  the  collateral  cir- 
culation with  the  carotid  of  the  other  side  is  so  free  as  to 
render  simple  proximal  ligation  much  less  likely  to  cure 
here  than  in  most  other  arteries.  Aneurisms  of  the  com- 


238  SURGERY    OF    THE    BLOOD-VESSELS. 

mon  carotid  or  of  the  internal  carotid  are  of  grave  sig- 
nificance because  of  the  disastrous  effect  on  the  brain  that 
often  follows  when  these  arteries  are  ligated.  The  dan- 
ger of  ligation  of  the  common  carotid  increases  enor- 
mously after  forty  years  of  age  and  is  due  to  the  dimin- 
ished blood  supply  to  the  brain.  In  the  young  with  elastic 
arteries  ligation  of  the  common  carotid  is  comparatively 
free  from  danger,  but  after  forty  years  of  age,  and  par- 
ticularly in  the  presence  of  arteriosclerosis,  the  occur- 
rence of  cerebral  symptoms,  from  the  inability  of  the 
other  arteries  to  dilate  sufficiently,  is  frequent.  The  op- 
erative measures  that  have  been  used  are  the  classical 
methods  of  ligation,  though  of  these  extirpation  with  the 
double  ligature  has  proved  most  successful.  Proximal 
ligature  is  particularly  liable  to  cause  thrombi  in  the 
sac  with  the  possibility  of  a  piece  of  thrombus  becoming 
loose  and  causing  an  embolus  in  the  brain.  This,  of 
course,  is  in  addition  to  the  danger  of  cerebral  symptoms 
from  the  mere  occlusion  of  the  artery.  Distal  ligation 
or  extirpation  to  a  large  extent  avoids  the  danger  of 
embolus. 

It  has  been  found  that  cerebral  symptoms  may  often 
be  avoided  if  the  channel  of  the  artery  can  be  reestab- 
lished within  a  few  hours  after  its  occlusion.  The  prob- 
lem in  connection  with  the  carotid  artery  is  different 
from  that  in  most  other  parts  of  the  body,  not  only  be- 
cause of  the  immediate  dangers  to  life,  but  because  of 
the  fact  that  we  have  a  method  of  determining  from  the 
patient's  sensations  and  symptoms  whether  occlusion  of 
the  artery  is  safe.  Before  applying  a  ligature  to  the 
carotid,  except  in  cases  of  grave  necessity,  the  common 
carotid  should  be  exposed  under  local  anesthetic  and 
gradually  occluded,  preferably  by  a  rubber  covered  Crile 
clamp.  If  this  is  followed  by  cerebral  symptoms  of  a 


ANEURISMS.  239 

psychic  nature,  by  paralysis  or  convulsions,  the  ml  cry 
should  be  opened  at  once.  If  no  immediate  symptoms 
occur,  the  clamp  may  be  left  on  for  forty-eight  hours 
and  then  a  ligature  applied  to  occlude  the  artery  with 
comparative  safety.  However,  cerebral  symptoms  some- 
times appear  after  several  days,  though  they  are  usually 
manifest  within  twenty-four  hours  after  occlusion  of  the 
artery.  If  complete  closure  is  not  possible  the  metal 
band  of  Halsted  may  be  rolled  around  the  artery  in  such 
a  manner  as  partially  to  occlude  it.  If  this  is  sufficient 
to  cure  the  aneurism  no  further  treatment  is  necessary; 
but  if  not  the  band  may  be  left  in  place  for  one  or  two 
weeks  until  the  other  arteries  have  taken  up  the  circula- 
tion, and  then  a  ligature  can  be  applied.  If  even  a  par- 
tial occlusion  is  not  borne  the  outlook  is  almost  hopeless, 
though  the  possibility  of  excision  and  the  substitution  of 
a  segment  of  vein  should  be  considered. 

Subclavian  aneurisms  have  been  subjected  to  numer- 
ous methods  of  treatment,  including  the  intrasaccular 
ligation  of  Syme.  They  have  been  treated  by  ligature, 
both  distal  and  proximal,  and  the  innominate  artery  has 
also  been  ligated  in  efforts  to  cure.  The  results  have 
usually  been  unsuccessful,  the  mortality  being  large, 
though  since  1890,  the  mortality  has  fallen  from  about 
eighty  percent  in  preantiseptic  days  to  twenty-two  per- 
cent. The  metal  band  may  also  be  used  here.  Excision 
of  the  sac  seems  to  have  been  followed  by  quite  satis- 
factory results  as  compared  to  other  methods  of  treat- 
ment. Endo-aneurismorrhaphy  has  been  attempted, 
though  in  not  a  great  number  of  cases,  and  the  results 
have  usually  been  most  satisfactory. 

Axillary  aneurisms  may  be  treated  by  ligature,  by 
band,  or  by  the  operation  of  Matas.  In  certain  cases 
where  the  circulation  can  be  controlled,  excision  of  the 


240  SURGERY    OF    THE    BLOOD-VESSELS. 

aneurism  with  substitution  of  a  piece  of  vein  may  be 
considered.  This  has  been  done  by  Lexer  and  while  the 
patient  died  from  gangrene  of  the  limb  it  was  found  that 
the  occlusion  from  thrombus  occurred  where  the  clamp 
was  placed,  the  transplanted  section  of  vein  being  patent 
and  in  good  condition. 

Treatment  of  aneurism  of  the  iliac  arteries  is  subject 
to  somewhat  the  same  objections  as  treatment  of  aneu- 
rism of  the  aorta,  for  ligation  of  these  large  arteries 
produces  great  strain  upon  the  heart.  The  intrasaccu- 
lar  method  of  Matas  offers  in  certain  cases  excellent  re- 
sults, though  hemostasis  may  be  difficult  or  impossible 
except  by  compression  of  the  aorta. 

The  common  and  external  iliac  may  be  regarded  as 
practically  an  extension  of  the  aorta.  Aneurisms  affect- 
ing all  of  the  iliac  arteries  are  lined  in  front  with  peri- 
toneum. They  tend  to  dilate  quickly  as  there  is  but  little 
resistance  in  front  and  they  rupture  easily  for  the  same 
reason.  When  rupture  occurs  it  is  usually  immediately 
fatal,  though  occasionally  the  blood  may  form  a  large 
hematoma  under  the  peritoneum.  The  treatment  of 
aneurisms  of  the  iliac  arteries  is  confined  to  some  form 
of  ligature,  to  a  partial  constriction  by  the  band  of 
Halsted,  or  to  endo-aneurismorrhaphy.  Digital  com- 
pression is  not  practical,  though  it  may  be  tried  by  open- 
ing the  abdomen  and  compressing  the  common  iliac  or 
the  aorta.  In  extirpation  or  in  endo-aneurismorrhaphy, 
temporary  hemostasis  can  be  effected  by  digital  pressure 
on  the  abdominal  aorta,  or  else  upon  the  trunk  of  the 
common  iliac  near  the  bifurcation.  Even  pressure  upon 
the  aorta  may  not  give  an  entirely  dry  field  as  some 
blood  comes  through  the  distal  end  by  the  deep  epigastric 
artery.  Pressure  upon  the  iliac  is  often  unsatisfactory 
because  of  the  free  anastomosis  with  the  internal  iliac  of 


ANEUKISMS.  '241 

the  other  side.  Aneurisms  of  the  external  iliac  have  oc- 
casionally been  treated  by  digital  compression.  Com- 
pression of  the  abdominal  aorta  through  the  abdominal 
wall  is  possible  in  thin  patients,  but  is  best  done  within 
the  abdomen.  In  a  thin  patient  the  method  of  Mom- 
burg,  constricting  the  abdomen  with  a  rubber  tube,  may 
be  tried.  This  will  give  a  completely  dry  field,  but  there 
is  always  some  danger  from  an  abdominal  tourniquet, 
such  as  injury  to  the  intestines,  though  the  originator  of 
this  method  claims  otherwise.  The  treatment  of  aneu- 
rism of  the  iliac  has  been  largely  by  means  of  the  liga- 
ture. Double  ligation,  distal  and  proximal,  with  extir- 
pation has  given  satisfactory  results.  The  iliac  should 
be  ligated  intraperitoneally.  The  older  method  of  strip- 
ping up  the  peritoneum  and  making  an  extensive  raw 
surface  is  unnecessary.  The  patient  may  be  put  in  the 
Trendelenburg  position  with  the  intestines  packed  off, 
and  ligation  of  either  the  common  iliac  or  its  two 
branches  can  be  readily  done.  Endo-aneurismorrhaphy 
has  been  tried  in  a  few  cases  with  satisfactory  results. 
Ligation  of  the  common  iliac  carries  a  heavy  mortality 
rate.  Matas  says  that  in  modern  times,  since  1880,  the 
death  rate  is  nearly  fifty  percent.  This  high  mortality 
rate,  as  explained  by  Halsted  in  an  article  on  aneurisms 
of  the  iliac,  is  largely  due  to  complications  and  would 
probably  now  be  considerably  lower.  The  fact,  however, 
that  the  mortality  from  simple  ligation  is  much  higher 
than  from  extirpation  or  endo-aneurismorrhaphy  should 
cause  the  later  method  to  be  employed  wherever  possible. 
Aneurisms  of  the  upper  femoral  require  a  similar 
hemostasis  to  aneurisms  of  the  iliac,  as  it  is  impractical 
to  place  a  tourniquet  at  this  level.  The  external  iliac 
gives  off  but  few  branches  whereas  the  upper  part  of  the 
femoral  has  a  very  abundant  collateral  circulation.  For 


SURGERY    OF    THE    BLOOD-VESSELS. 

this  reason  in  preantiseptic  days  ligation  of  the  femoral 
just  below  the  groin  was  avoided  whenever  possible. 
The  collateral  circulation  was  so  free  at  this  point  that 
formation  of  a  thrombus  was  prevented  or  retarded  and 
as  suppuration  usually  took  place  secondary  hemorrhage 
would  occur  in  about  half  of  all  cases ;  consequently,  the 
external  iliac  whose  branches  are  few  could  be  ligated 
much  more  safely.  However,  now  with  the  absorbable 
ligature  and  careful  asepsis,  these  objections  no  longer 
hold. 

In  aneurisms  of  the  upper  femoral  it  is  exceedingly 
difficult  to  obtain  even  temporary  hemostasis  unless  the 
same  measures  are  employed  as  in  aneurisms  of  the  iliac ; 
that  is,  direct  compression  of  the  abdominal  aorta  or  the 
common  iliac  after  opening  the  abdomen.  The  commu- 
nications of  the  profunda,  which  is  almost  always  in  the 
sac  of  an  aneurism  in  this  neighborhood,  together  with 
other  collateral  branches  make  the  field  very  vascular. 
The  necessity  for  controlling  bleeding  by  intraabdominal 
pressure  in  such  cases  should  be  considered  most  seri- 
ously whenever  it  is  desired  to  open  the  sac  of  an  upper 
femoral  aneurism. 

Aneurism  of  the  branches  of  the  internal  iliac  prac- 
tically always  occurs  either  outside  of  the  pelvis  or  else 
partly  without  and  partly  within  the  pelvis.  It  usually 
involves  the  sciatic  or  the  giuteal  arteries.  Formerly, 
the  most  satisfactory  treatment  was  the  method  of  An- 
tyllus  where  the  vessel  is  ligated  both  proximally  and 
distally  and  the  sac  incised.  The  better  method  is  endo- 
aneurismorrhaphy  with  either  temporary  or  permanent 
closure  of  the  internal  iliac  by  ligature.  When  the  aneu- 
rism begins  in  the  pelvis,  which  is  very  unusual,  merely 
ligating  the  internal  iliac  may  be  all  that  is  necessary. 

Aneurism  of  the  lower  femoral  can  be  treated  most 


ANEURISMS.  '24'.\ 

satisfactorily  by  endo-aneurismorrhaphy  and  lie  re,  as 
elsewhere,  either  the  obliterative  or,  sometimes,  the 
restorative  operation  is  done.  The  reconstructive 
method,  an  attempt  to  build  up  a  new  channel  out  of  the 
wall  of  the  sac,  should  not  be  attempted.  If  after  test- 
ing the  collateral  circulation  it  appears  deficient  and  the 
patient's  condition  is  otherwise  good,  the  possibility  of 
excising  the  aneurism  and  substituting  a  piece  of  the 
saphenous  vein  from  the  other  leg  should  be  considered. 
Popliteal  aneurisms  may  involve  the  whole  of  the  ar- 
tery in  the  later  stages,  but  in  the  early  stages  they  are 
often  of  the  saccular  form  in  which  a  very  small  portion 
of  the  artery  is  affected.  In  several  instances  the  aneu- 
rism has  been  excised  and  the  ends  of  the  artery  united 
by  end-to-end  suture.  Aneurisms  arising  from  the  up- 
per part  of  the  popliteal  are  much  less  likely  to  cause 
gangrene  than  those  from  the  lower  portion  of  this  ar- 
tery, because  most  of  the  collateral  circulation  from  the 
articular,  azygos,  and  muscular  branches  opens  into  the 
lower  portion  of  the  popliteal.  The  former  treatment 
of  popliteal  aneurism  was  peculiarly  unsuccessful.  Va- 
rious methods  of  ligation  have  been  used.  As  popliteal 
aneurisms  comprise  about  one-third  of  all  aneurisms,  ex- 
cepting those  of  the  aorta,  the  clinical  material  for  op- 
erative treatment  has  been  very  largely  drawn  from 
those  of  the  popliteal  type.  Of  the  various  methods  of 
ligation  the  Hunterian  has  been  the  most  popular,  but 
the  radical  operation  consisting  either  of  extirpation  of 
the  sac  or  the  operation  of  Antyllus,  a  distal  and  a  prox- 
imal ligature  and  incision  of  the  sac,  has  given  better 
results.  Endo-aneurismorrhaphy  is  peculiarly  applica- 
ble to  popliteal  aneurisms  and  in  sixty-two  cases  there 
was  only  one  death  which  was  due  to  tetanus  and  two 
cases  of  gangrene,  and  in  both  of  these  instances  the  vein 


244  SURGERY    OF    THE    BLOOD-VESSELS. 

that  accompanied  the  artery  was  injured  and  had  to  be 
ligated.  This,  of  course,  was  not  a  fault  of  the  method. 
In  all  others  recovery  occurred.  There  were  secondary 
hemorrhage  and  relapse  in  four  cases,  but  in  these  the 
reconstructive  method  was  used,  proving  the  wisdom  of 
adopting  the  obliterative  type  of  endo-aneurismorrhaphy. 
In  one  of  the  author's  cases  in  which  the  obliterative  op- 
eration was  done  for  a  popliteal  aneurism,  the  result  was 
entirely  successful. 


CHAPTER  XIII. 
ARTERIOVENOUS  ANEURISMS. 

Arteriovenous  aneurisms  are  lesions  in  which  there  is 
a  communication  between  an  artery  and  a  vein.  The 
vein  may  be  a  sinus  in  the  dura  mater.  They  are  usu- 
ally subdivided  into  two  forms,  varicose  aneurism,  in 
which  the  communication  between  the  artery  and  vein  is 
indirect  and  a  sac  exists  between  the  two  vessels;  and 
aneurismal  varix,  in  which  the  blood  flows  directly 
through  the  opening  from  the  artery  into  the  vein. 
There  are  many  combinations  such  as  a  sac  in  the  artery 
opposite  the  opening  into  the  vein  or  there  may  be  two 
sacs,  one  on  the  artery  opposite  the  opening  and  one  be- 
tween the  artery  and  the  vein.  The  vein  becomes  di- 
lated, particularly  the  proximal  vein,  unless  the  parts 
around  it  form  a  firm  support.  Dilatation  of  the  vein 
is  called  varicose  aneurism  by  dilatation. 

Secondary  arteriovenous  aneurisms  are  found  in  the 
region  of  the  heart  and  around  the  aorta  where  a  pre- 
existing aneurism  has  ruptured  into  a  vein.  The  most 
frequent  cause  of  arteriovenous  aneurism  is  trauma,  a 
gunshot  wound  being  the  common  form  of  traumatism. 
The  modern  bullet  which  makes  a  small  puncture  is  very 
likely  to  cause  an  injury  of  this  nature.  Formerly, 
when  bleeding  was  in  vogue,  arteriovenous  aneurism  at 
the  elbow  with  a  communication  between  the  brachial 
or  the  ulnar  artery  and  a  vein,  was  comparatively  fre- 
quent. Fractures,  stabs,  or  indirect  injuries  may  also 
result  in  arteriovenous  aneurism,  but  occasionally  it  oc- 

245 


246  SURGERY    OF    THE    BLOOD-VESSELS. 

curs  spontaneously,  which  is  rare  and  is  probably  due 
to  some  degeneration  in  the  wall  of  the  artery  that  per- 
mits perforation  at  this  point.  The  distal  portion  of 
the  artery  becomes  contracted  and  narrow,  since  it  is 
subject  to  less  than  its  normal  pressure  as  a  portion  of 
the  blood  intended  for  it  is  delivered  to  the  vein.  The 
central  segment  of  the  artery,  however,  is  much  dilated. 
This  was  supposed  at  one  time  to  be  due  to  a  kind  of 
atrophy  and  thinning  of  its  walls,  but  is  now  believed  to 
be  a  genuine  hypertrophy  of  the  vessel  itself  in  an  effort 
to  bring  enough  blood  to  the  seat  of  the  lesion  to  sup- 
ply the  distal  parts  satisfactorily  even  in  the  presence 
of  the  leak  into  the  vein.  The  vein  is  also  dilated  dis- 
tally  up  to  the  first  valve  and  centrally  for  a  much  longer 
distance.  Sometimes  the  valves  are  forced  by  the  pres- 
sure of  the  blood  stream  or  by  damming  back  of  the 
blood  and  a  large  varicose  tumor  may  result.  The  dila- 
tation of  the  vein  is  very  much  influenced  by  the  sur- 
rounding tissue.  The  vein  gradually  thickens  and  be- 
comes more  and  more  like  an  artery. 

Owing  to  the  marked  activity  of  the  circulation  in  ar- 
teriovenous  aneurisms  and  the  great  difference  in  pres- 
sure between  the  venous  and  the  arterial  trunks,  clots 
rarely  form  and  the  prospect  of  spontaneous  cure  is  very 
slight  indeed.  The  liability  to  rupture  depends  to  a 
large  extent  upon  the  size  and  location  of  the  sac.  An 
aneurismal  varix  rarely  ruptures.  Sometimes  the 
crowding  of  the  arterial  blood  into  the  vein  causes  swell- 
ing from  damming  back  of  the  venous  blood,  and  at  the 
same  time  nutritional  disturbances  may  appear  because 
too  little  blood  enters  the  artery  distal  to  the  lesion.  All 
of  these  things,  however,  depend  entirely  upon  the  loca- 
tion of  the  arteriovenous  aneurism  and  the  size  of  the 
opening.  A  very  small  leak  will  interfere  but  little, 


ARTERIOVENOUS    ANEURISMS.  247 

whereas  a  larger  one  may  switch  back  so  much  of  tin- 
blood  that  nutrition  is  greatly  impaired. 

In  large  arteries  an  opening  of  considerable  size  may 
cause  so  much  pressure  in  the  venous  system  as  to  pro- 
duce dilatation  or  hypertrophy  of  the  heart.  In  a  case 
that  the  author  operated  upon  (page  252)  there  was  a 
large  opening  between  the  upper  femoral  artery  and 
vein,  and  all  four  valves  of  the  heart  were  incompetent. 
The  lesion  may  appear  immediately  after  the  infliction 
of  the  injury  or  more  frequently  after  an  interval  of 
time.  Some  cases  are  reported  in  which  the  symptoms 
occur  months  or  years  after  the  injury,  but  this  is  un- 
usual and  is  probably  due  to  yielding  of  the  scar.  Usually 
the  clots  and  the  pressure  from  the  surrounding  exudate 
will  prevent  a  free  communication  for  several  days. 

The  thrill  is  marked  in  all  arteriovenous  communica- 
tions. It  can  be  felt  distinctly  at  the  site  of  the  lesion 
and  along  the  course  of  the  vein  both  distally  and  cen- 
trally. The  bruit  can  be  heard  and  is  much  more  dis- 
tinct than  in  simple  aneurisms  of  arteries.  Often  the 
vibrations  along  the  course  of  the  vein  can  be  seen.  The 
thrill  is  continuous  but  is  most  intense  with  each  systole 
of  the  heart  and  at  the  exact  site  of  the  anastomosis. 
The  noise  has  been  compared  to  the  buzzing  of  machin- 
ery, or  to  the  sound  made  by  a  bee  in  a  paper  bag.  This 
sound  varies  in  character  and  in  pitch  but  is  present 
in  some  degree  at  all  times.  It  ceases  completely  when 
the  artery  is  compressed  on  the  cardiac  side  of  the  le- 
sion. It  is  caused  by  the  vibration  produced  from  the 
rapid  whirl  of  the  blood  current  in  going  suddenly  from 
a  vessel  of  high  pressure  to  a  cavity  of  low  pressure,  just 
as  a  noise  is  made  by  the  passing  of  water  from  a  high 
pressure  pipe  to  one  of  low  pressure.  Neither  the  edges 
of  the  opening  nor  the  vessels  have  anything  to  do  with 


248  SURGERY    OF    THE    BLOOD-VESSELS. 

the  sound,  which  is  produced  solely  by  the  blood  cur- 
rent. 

The  pulse  in  the  artery  is  stronger  above  the  lesion 
and  weaker  below  the  lesion  than  it  would  be  normally. 
It  is  also  somewhat  delayed  below  the  lesion.  Pulsa- 
tion in  the  vein  is  sometimes  felt,  though  this  depends 
upon  the  size  of  the  opening  and  also  upon  the  size  of 
the  artery.  Pressure  upon  the  artery  centrally  to  the 
lesion  not  only  stops  the  sound  but  also  causes  a  marked 
diminution  in  the  size  of  the  tumor.  Superficial  veins  in 
the  neighborhood  are  usually  enlarged.  The  tempera- 
ture of  the  limb  distal  to  the  aneurism  is  lowered,  at 
least  until  a  satisfactory  collateral  circulation  has 
formed. 

If  a  large  communication  exists  between  the  aorta  or 
the  iliac  arteries  and  the  adjoining  vein,  the  prognosis  is 
most  unfavorable.  The  decrease  in  blood  pressure  be- 
cause of  the  large  leak  from  the  arterial  system  into  the 
venous  system,  which  has  a  much  larger  capacity,  might 
so  lower  the  blood  pressure  as  to  cause  death. 

The  prognosis  of  arteriovenous  aneurisms  depends 
upon  three  things :  first,  the  location,  whether  in  a  large 
or  a  small  vessel;  second,  the  size  of  the  opening;  and 
third,  the  presence  or  absence  of  a  sac.  A  large  open- 
ing in  large  vessels,  even  if  the  blood  pressure  could  be 
maintained,  is  likely  to  put  too  great  a  strain  upon  the 
heart.  On  the  other  hand,  an  arteriovenous  aneurism 
in  a  small  artery  is  of  but  little  significance  and  would 
interfere  very  slightly  with  function  or  with  the  general 
health.  There  is  but  slight  chance  of  rupture,  when  com- 
pared with  aneurisms  of  the  arteries,  and  this  infre- 
quency  of  rupture  with  the  difficulty  of  cure  has  led  the 
older  surgeons  to  avoid  interference  in  arteriovenous 
aneurisms. 


AKTEEIOVENOUS   ANEUEISMS.  l!4(> 

Treatment. 

It  has  been  the  experience  of  most  surgeons  who  have 
had  considerable  clinical  material  that  unless  there  is 
grave  danger  it  is  best  not  to  operate  upon  these  in- 
juries too  soon.  The  patient  should  be  given  the  benefit 
of  rest  and  kept  as  quiet  as  possible  to  reduce  blood 
pressure.  This  treatment  is  continued  for  two  or  three 
months  after  the  injury  unless  there  is  a  marked  tend- 
ency for  the  lesion  to  become  worse.  At  this  time  what- 
ever sac  may  have  occurred  will  be  firmly  organized  and 
the  collateral  circulation  will  be  amply  established.  Re- 
cent experience  in  the  Balkan  wars,  however,  seems  to 
indicate  that  immediate  operation  is  best. 

Immediately  after  the  injury,  pressure  over  the  lesion 
and  on  the  main  artery  by  a  firm  dressing  and  bandage 
and  absolute  rest  are  indicated.  The  various  methods 
of  ligation  have  not  proved  very  satisfactory.  Proxi- 
mal ligation  is  often  followed  by  recurrence  and  distal 
ligation  alone  is,  of  course,  never  indicated.  The  quad- 
ruple ligation,  tying  artery  and  vein  both  above  and  be- 
low, with  or  without  extirpation  of  the  sac,  has  cured 
most  cases,  but  is  often  followed  by  gangrene  owing  to 
the  fact  that  both  the  artery  and  vein  are  sacrificed  at 
the  same  time. 

The  ideal  method  of  treatment  is  restoration  of  the 
lumen  of  both  the  artery  and  vein.  Where  a  sac  exists, 
the  method  of  Matas,  the  restorative  endo-aneurismor- 
rhaphy,  may  be  practiced  in  some  cases.  The  fact,  how- 
ever, that  the  sac  is  practically  always  a  false  sac  and 
is  not  continuous  with  any  of  the  coats  of  either  artery 
or  vein  would  make  the  application  of  this  method  a 
little  less  certain  than  in  a  restorative  endo-aneu- 
rismorrhaphy  on  a  spontaneous  aneurism.  If  a  sac  ex- 


250  SURGERY    OF    THE    BLOOD-VESSELS. 

ists  it  is  opened,  and  the  aperture  in  the  artery 
sutured  with  interrupted  catgut  stitches.  AVlien  the 
artery  and  vein  are  both  closed  in  this  manner  the  sac  is 
partly  obliterated  by  catgut  stitches  which  tuck  a  por- 
tion of  the  sac  over  each  opening.  In  an  aneurismal 
varix  the  vein  may  be  incised  and  the  opening  into  the 
artery  is  closed  within  the  vein,  then  the  vein  itself  is 
sutured.  This  latter  procedure  probably  causes  a  throm- 
bus in  the  vein  even  if  the  suturing  in  the  artery  held. 
If  it  is  possible  to  secure  complete  hemostasis  the 
most  satisfactory  way  is  to  dissect  free  both  the  artery 
and  vein  and  to  suture  the  wound  in  each  vessel,  follow- 
ing the  technique  of  arterial  suturing.  This,  of  course, 
would  necessitate  the  edges  of  the  wound  in  the  artery 
and  vein  being  carefully  cut  away  with  sharp  scissors, 
the  adventitia  removed,  and  the  wound  approximated  ac- 
cording to  the  technique  described  under  the  head  of  su- 
turing lateral  or  transverse  wounds  in  blood-vessels. 
As  much  tissue  as  possible  should  be  preserved  so  that  a 
double  mattress  stitch  may  be  used,  approximating  ac- 
curately the  intima  and  at  the  same  time  not  sacri- 
ficing the  lumen.  The  dilatation  of  the  vessels  toward 
the  heart,  together  with  the  contraction  below  the  lesion, 
places  considerably  more  strain  upon  the  sutures  than 
would  be  the  case  after  an  ordinary  wound  of  the  vessel. 
This  strain  should  be  relieved  by  the  application  of  a 
strip  of  fascia,  a  large  absorbable  ligature,  the  Halsted 
aluminum  band  or  infolding  the  artery  according  to 
Matas  and  Allen,  in  order  partly  to  occlude  the  vessel 
proximal  to  the  lesion.  Or  a  ligature  may  be  thrown 
around  the  artery  with  instructions  to  tie  it  quickly  if 
secondary  hemorrhage  occurs.  If  there  is  no  infection 
the  danger  from  secondary  hemorrhage  should  be  over 
in  a  week  or  ten  days. 


AETERIOVENOUS    ANEUKISMS. 

When  it  is  impossible  or  impracticable  to  secure  com- 
plete liemostasis  by  a  tourniquet  the  problem  is  much 
more  difficult.  If  the  nutrition  of  the  limb  is  seriously 
affected,  or  if  the  heart  shows  signs  of  failing  under  the 
extra  strain  on  the  venous  side,  operation  should  be  at- 
tempted. In  a  heart  that  is  already  incompetent,  pres- 
sure upon  the  aorta  or  ligation  of  a  large  vessel  might 
result  disastrously  and  the  safer  method  under  such 


I    - .     m^mmim^m  H.V-V 

Fig.  73. — This  shows  how  the  clamps  for  lateral  suture  may  be  applied  on  an 
arteriovenous  aneurism  without  the  necessity  of  fully  dissecting  out  the 
aneurism. 


circumstances  would  be  to  reestablish  the  circulation  in 
both  the  artery  and  vein.  Here  it  is  advisable  to  dissect 
both  vessels  carefully,  exposing  the  lesion  and  then  to 
grasp  the  artery  and  the  vein  with  curved  forceps  for 
lateral  suture  of  blood-vessels  (page  85).  After  grasp- 
ing the  artery  and  vein  their  communication  is  severed, 
the  edges  of  the  wound  in  the  vessels  properly  trimmed, 
and  with  a  cobbler's  stitch  in  straight  arterial  needles 
or  an  overhand  stitch  in  a  curved  needle,  the  opening  in 
the  artery  and  then  in  the  vein  is  closed  (Figs.  73  and 


252 


SURGERY    OF    THE    BLOOD-VESSELS. 


74).  If  possible  without  too  much  constriction  of  the 
lumen,  a  continuous  reenforcing  stitch  over  this  may 
also  be  used.  The  lumen  of  the  artery  should  be  par- 
tially occluded  on  the  cardiac  side,  as  already  mentioned. 
A  case  of  arteriovenous  aneurism  between  the  femoral 
artery  and  vein  about  two  inches  below  Poupart's  liga- 
ment on  which  the  author  operated  at  a  clinic  in  the 
Medico-Chirurgical  College,  through  the  courtesy  of 
Prof.  W.  L.  Rodman,  may  be  of  interest  in  this  connec- 


Fig.    74. — The 


1. — The  communication  between  the  artery  and  vein  has  been  divided  an( 
the  vessels  are  being  sutured.  It  is  best  to  use  a  cobbler's  stitch  and  fin< 
arterial  needles  in  the  artery,  but  if  this  is  impossible,  a  fine  curved  needl 
may  be  used. 


tion.  Four  years  ago,  the  patient,  a  pullman  car  por- 
ter, had  fallen  on  a  sharp  stick  and  injured  his  left 
thigh  about  two  inches  below  Poupart's  ligament.  Sev- 
eral months  after  the  wound  had  healed,  he  noticed  a 
swelling  in  this  location.  It  would  sometimes  be  quite 
large.  Gradually  the  pain  became  greater  and  greater 
and  it  was  difficult  for  him  to  work.  On  admission  to 
the  Medico-Chirurgical  Hospital,  all  valves  of  the  heart 
were  found  incompetent  and  the  thrill  and  bruit  in  the 


ARTERIOVENOUS    ANEURISMS.  2."))} 

region  of  the  scar  were  intense.  The  pressure  in  the 
venous  system  was  evidently  so  great  as  to  affect  his 
heart  most  seriously  and  the  indication  was  to  relieve 
his  heart  by  an  attempt  to  cure  the  arteriovenoiis  aneu- 
rism. The  location  was  too  high  for  a  tourniquet  and 
the  condition  of  the  patient's  heart  rendered  it  unwise 
to  compress  the  aorta.  After  carefully  dissecting  free 
the  vessels  involved,  the  femoral  artery  just  above  the 
lesion  was  found  greatly  enlarged  and  the  femoral  vein 
much  dilated.  In  an  effort  to  free  the  artery  posteriorly, 
considerable  bleeding  was  encountered.  The  profunda 
artery  was  clamped  and  the  vessels  going  internally 
cut  and  tied,  as  they  hindered  the  dissection.  Adhesions 
from  the  scar  tissue  posteriorly  and  numerous  vessels 
here  that  tore  easily  rendered  the  dissection  behind  the 
femoral  impossible.  Though  a  Crile  clamp  was  placed  on 
the  artery  above  and  below  the  lesion  and  also  similarly 
on  the  vein,  and  though  the  profunda  was  clamped,  the 
communication  between  the  femoral  artery  and  vein  when 
incised  bled  freely.  The  tip  of  the  index  finger  was  at 
once  inserted  and  in  this  manner  the  bleeding  was  checked. 
The  vein  was  clamped  by  a  soft  Doyen  intestinal  clamp. 
Pressure  over  the  artery  in  certain  directions  controlled 
the  collateral  branches  that  evidently  came  in  from  be- 
hind. No  attempt  was  made  to  follow  the  regular  tech- 
nique of  arterial  suturing  as  the  vessels  would  bleed  pro- 
fusely after  pressure  was  removed  and  it  was  impossible 
to  do  the  suturing  in  a  perfectly  dry  field.  The  thread, 
however,  was  anointed  with  vaseline  and  the  wound  in 
the  artery  was  closed  by  a  continuous  stitch  of  moder- 
ately fine  silk  in  a  curved  needle.  The  wound  in  the  vein 
was  easily  sutured.  The  distal  clamp  was  removed  and 
the  proximal  clamp  was  gradually  loosened.  The  ex- 
ceedingly large  size  of  the  femoral  artery  above  and  the 


254  SURGERY    OF    THE    BLOOD-VESSELS. 

impossibility  of  carrying  out  the  regular  technique  of 
arterial  suturing  made  it  doubtful  whether  the  sutures  in 
the  artery  would  hold.  At  the  same  time  it  was  recog- 
nized that  ligation  of  the  dilated  femoral  would  throw  so 
much  extra  strain  upon  a  heart  whose  valves  were  already 
incompetent  that  a  cardiac  death  might  result.  Conse- 
quently, ligatures  were  placed  around  the  artery  and 
vein,  both  above  and  below  the  lesion,  with  the  idea  of  ty- 
ing these  ligatures  if  serious  hemorrhage  occurred  later. 
The  wound  was  perfectly  dry  when  closed.  There  was  a 
small  drainage  provided  at  both  the  upper  and  lower 
angles.  The  night  following  the  operation  considerable 
hemorrhage  occurred  and  the  ligatures  were  tied  and  an 
additional  ligature  placed  on  the  artery.  The  next 
morning  the  patient's  pulse  was  good  and  the  leg  was 
warm  and  seemed  to  be  well  supplied  with  blood.  He 
did  well  for  fifteen  days  when  he  had  a  severe  secondary 
hemorrhage,  for  which  Dr.  Rodman  ligated  the  external 
iliac.  This  completely  controlled  the  hemorrhage  and 
the  patient  was  apparently  improving  until  the  twenty- 
first  day  after  the  operation,  when  symptoms  of  acute 
cardiac  dilatation  occurred  and  he  died  within  twenty- 
four  hours.  There  had  been  no  further  hemorrhage, 
however,  and  a  post-mortem  examination  showed  there 
was  no  bleeding,  but  that  death  was  due  to  dilatation  of  the 
heart.  Such  cases  are  always  desperate  but  if  they  can 
be  treated  before  the  heart  becomes  so  markedly  dis- 
eased the  prognosis  would  be  better. 


CHAPTER  XIV. 
TUMORS  OF  THE  BLOOD-VESSELS. 

A  true  tumor  of  the  blood-vessels  springs  from  a  ma- 
trix of  cells  that  is  formed  either  in  the  embryo  or  in 
later  life.  It  is  not  a  part  of  the  normal  anatomical 
structure.  Tumors  of  blood-vessels  may  consist  chiefly 
of  arteries,  chiefly  of  veins,  or  chiefly  of  capillaries,  but 
all  have  to  some  extent  other  types  of  blood-vessels. 
They  are  named,  however,  after  the  predominant  type. 
The  kind  very  commonly  found  is  composed  of  dilated 
capillaries  that  lie  within  the  skin.  They  produce  the 
color  often  referred  to  as  "port-wine  mark,"  due  to  the 
large  number  of  new  dilated  capillaries.  If  chiefly  from 
the  arterioles,  the  color  is  decidedly  red;  if  the  dilata- 
tion is  largely  on  the  venous  side  it  is  dark  purple.  The 
skin  is  usually  not  elevated  above  the  normal  and  the 
appearance  is  suggestive  of  a  deep  and  irregular  stain. 
Some  authors  have  claimed  that  these  capillary  angiomas 
follow  the  distribution  of  the  branches  of  the  fifth  nerve, 
though  these  findings  are  not  generally  borne  out  by 
other  observers. 

Gushing  suggested  that  these  angiomas  are  often 
found  in  the  dura  when  present  on  the  face  and  not  in- 
frequently cause  hemorrhage,  which  may  be  serious. 
Such  a  possibility  should  be  borne  in  mind  in  all  cases 
in  which  sudden  cerebral  symptoms  arise  in  a  patient 
who  has  a  capillary  angioma  on  the  face. 

The  histologic  appearance  shows  a  large  number  of 
well  formed  capillaries  and  small  blood-vessels,  and  fre- 

255 


256  SURGERY    OF    THE    BLOOD-VESSELS. 

quently  many  lymph  vessels.  The  growth  is  painless, 
though  the  disfigurement  is  so  marked  that  it  may  be  the 
cause  of  nervous  symptoms  in  a  person  of  sensitive  na- 
ture. 

Treatment  depends  to  some  extent  upon  the  location 
and  extent  of  the  growth.  If  small  and  conspicuous  it 
can  usually  be  excised  and  the  skin  around  the  edges 
undermined  so  as  to  bring  the  margins  of  the  wound  to- 
gether in  a  straight  line.  The  skin  should  be  sewed  sub- 
cutaneously  to  leave  but  little  scar.  A  subcuticular 
stitch  of  tanned  catgut  makes  a  very  satisfactory  union. 
This  may  be  reenforced  by  the  epithelial  stitch  of  Hal- 
sted,  fine  silk  in  a  fine  round  needle,  merely  taking  the 
edges  of  the  epidermis.  If,  however,  the  angioma  is  ex- 
tensive as  is  often  the  case,  other  measures  are  prefer- 
able. 

The  many  kinds  of  treatment  formerly  employed,  such 
as  the  application  of  nitro-muriatic  acid,  cauterization 
with  the  actual  cautery,  or  the  injection  of  astringent  so- 
lutions, have  now  been  practically  abandoned.  If  the 
nevus  is  too  extensive  for  excision  it  should  be  treated 
either  by  electricity,  carbon  dioxide  snow,  or  liquid 
air.  The  older  method  of  electrical  treatment  consisted 
in  inserting  a  needle  into  the  growth  at  various  spots 
and  connecting  it  with  the  negative  pole  of  a  galvanic 
battery.  A  current  of  about  twenty  milliamperes  was 
turned  on  for  about  ten  minutes  and  increased  shortly 
before  withdrawing  the  needle.  This  has  to  be  repeated 
often  and  frequently  leaves  considerable  scar.  The  mod- 
ern electrical  treatment  by  desiccation  is  far  better.  The 
bare  electrode  does  not  come  in  contact  with  the  tissues, 
but  the  current  from  one  pole  is  thrown  from  a  metal  part 
through  a  small  air  space  in  the  form  of  sparks  of  high 
frequency.  The  other  pole  is  grounded.  If  deeper  ef- 


TUMORS    OF    BLOOD-VESSELS.  _•)< 

feet  is  desired  the  bipolar  method  is  used.  Here  the 
metal  point  touches  the  tissues  and  a  large  passive  elec- 
trode is  placed  on  some  other  portion  of  the  body.  A 
static  machine  with  an  output  of  from  two  and  a  halt'  to 
three  and  a  half  milliamperes  produces  a  satisfactory 
initial  current  which  is  gradually  increased.  Desicca- 
tion seems  to  dry  the  tissues  and  sterilize  them.  It  causes 
a  rapid  dehydration  and  ruptures  the  cell  capsule.  It  has 
the  power  of  penetrating  the  tissues  for  as  much  as  an 
inch,  though  usually  it  penetrates  efficiently  only  for  a 
much  shorter  distance.  A  small  growth  may  possibly  be 
destroyed  at  one  sitting  but  a  large  growth  requires  sev- 
eral treatments.  The  desiccated  tissue  causes  a  reac- 
tion and  hyperemia  which  usually  produces  rapid  repair. 
The  crust  that  forms  separates  in  a  few  days  or  a  week. 
Often  regeneration  will  occur  without  scar.  The  appli- 
cation is  not  very  painful,  but  if  the  individual  is  sensi- 
tive a  local  anesthetic  may  be  employed.  This  treat- 
ment should  not  be  used,  however,  when  there  is  any 
reasonable  suspicion  of  malignancy. 

Another  method  of  treating  extensive  nevi  or  birth- 
marks is  refrigeration.  It  gives  most  satisfactory  re- 
sults. Carbon  dioxide,  which  is  employed  for  freezing, 
is  readily  procurable  in  iron  drums  from  soda  water 
manufacturers  or  from  saloons  where  beer  is  sold.  To 
collect  the  frozen  gas  or  "snow,"  as  it  is  called,  the  iron 
drum  is  tilted  till  the  outlet  is  at  a  low  point.  This  in- 
sures the  exit  of  the  liquid.  A  piece  of  chamois  skin  is 
then  tied  around  the  outlet  and  collects  the  frozen  gas. 
Special  attachments  are  also  on  the  market  for  collect- 
ing the  gas.  If  chamois  skin  is  employed  the  "snow" 
can  be  rolled  in  the  chamois  skin  or  packed  in  hard  rub- 
ber molds  to  form  a  stick  or  pencil.  Any  grade  of  re- 
frigeration may  be  obtained,  depending  upon  the  dura- 


258  SURGERY    OF    THE    BLOOD-VESSELS. 

tion  of  the  application  and  the  amount  of  pressure.  For 
small  lesions,  about  the  size  of  a  nickel  or  smaller,  one 
application  usually  suffices.  For  larger  growths,  sev- 
eral are  necessary.  For  the  ordinary  flat  nevus  an  ap- 
plication of  from  ten  to  thirty  seconds  is  enough.  When 
used  on  large  nevi  that  are  somewhat  deeper  and  with 
a  thick  skin,  an  application  of  a  minute  or  more  may  be 
necessary.  Some  authorities  claim  that  exposure  to  X- 
ray  renders  the  tissue  more  susceptible  to  freezing.  The 
treatment  is  followed  by  a  disagreeable  burning  sensa- 
tion and  usually  by  blistering.  Ordinary  dusting  pow- 
der of  borated  talcum  is  used  as  a  simple  after-treat- 
ment. The  principle  of  both  refrigeration  and  desicca- 
tion is  that  the  endothelial  cells  of  the  blood-vessels  are 
destroyed  and  consequently  the  vessels  disappear. 

In  capillary  nevi,  "port-wine  marks,"  the  small  capil- 
laries are  dilated  either  in  a  spindle-shape  or  in  a  sac- 
cular  form.  In  the  cavernous  or  venous  angioma,  the 
vessels  are  larger  and  more  deeply  situated  and  desicca- 
tion or  freezing  is  inapplicable,  as  these  remedies  cannot 
penetrate  deeply  enough  to  destroy  all  of  the  elements 
of  the  anigoma  without  causing  an  extensive  slough.  A 
cavernous  angioma  is  raised  above  the  surface  and 
sometimes  attains  very  large  proportions.  It  is  soft 
and  easily  compressible,  the  blood,  however,  filling  up 
the  growth  quickly  whenever  pressure  is  removed.  A 
venous  angioma  may  arise  as  a  growth  of  new  veins  or 
it  occasionally  occurs  as  a  sequence  of  a  capillary  angi- 
oma that  tends  to  grow  deeper  into  the  tissue,  its  ves- 
sels communicating  and  forming  large  lakes  of  blood. 
The  walls  of  a  cavernous  angioma  are  very  thin  and 
they  may  be  easily  injured.  A  wound  of  such  a  growth 
is  followed  by  profuse  and  sometimes  fatal  bleeding. 
Cavernous  angiomas  are  seen  on  the  face  frequently,  as 


TUMORS    OF    BLOOD-VESSELS.  259 

is  the  capillary  angioma  or  nevus,  and  are  also  found  in 
the  liver,  muscles,  and  sometimes  in  the  kidney  and  other 
organs.  The  nose  or  the  margins  of  the  eye  are  favor- 
ite portions  of  the  face  for  this  growth.  It  is  said  that 
it  is  likely  to  occur  where  the  fissures  of  the  face  are 
obliterated. 

The  treatment  for  capillary  angioma  or  nevus  is 
hardly  applicable  to  cavernous  or  venous  angiomas, 
except  so  far  as  they  may  be  excised.  Radium,  however, 
can  be  used  for  any  kind  of  angioma.  It  seems  to  have  a 
special  tendency  to  cause  obliteration  of  blood-vessels. 
Care  should  be  taken  in  excision  not  to  cut  through  the 
tumor  tissue  itself,  as  almost  uncontrollable  hemorrhage 
may  be  encountered.  If  such  a  growth  lias  been  acci- 
dentally injured  it  is  useless  to  attempt  to  catch  the  indi- 
vidual vessels  but  sterile  gauze  should  be  packed  in  the 
wound  and  firm  compression  made.  This  packing  should 
not  be  removed  for  several  days.  In  excision  the  cut  is 
made  in  healthy  tissues  where  normal  vessels  are  encoun- 
tered and  the  blood  supply  dealt  with  in  the  usual  man- 
ner. In  large  angiomas,  however,  this  would  be  imprac- 
ticable and  often  the  excision  of  so  much  tissue  leaves 
a  very  bad  deformity.  Most  angiomas  have  a  congeni- 
tal origin  and  sometimes  grow  rapidly,  and  the  effects 
of  their  pressure  upon  the  surrounding  tissue,  even 
upon  the  bone  itself,  may  cause  atrophy  and  leave1 
marked  deformity.  Another  objection  to  excision  in  any 
but  the  smallest  tumors  is  the  fact  that  frequently  ma- 
trices of  the  blood-vessels,  angioblasts,  may  exist  around 
the  margin  of  the  growth  in  what  appears  to  be  healthy 
tissue;  small  blood-vessels  from  the  growth  also  jut  out 
irregularly.  In  order  to  include  these,  a  wide  margin 
of  healthy  tissue  would  have  to  be  removed,  else  some  of 
the  abnormal  vessels  left  may  renew  the  growth. 


260  SURGERY    OF    THE    BLOOD-VESSELS. 

The  treatment  devised  by  John  A.  \Vyetli,  of  New 
York,  is  most  satisfactory  for  cavernous  angiomas  that 
cannot  readily  be  excised.  This  consists  of  the  injection 
of  boiling  water  into  the  growth.  The  water  mixes  with 
the  blood  and  the  heat  destroys  the  endothelial  lining 
of  the  blood-vessels.  In  a  large  growth  a  series  of  in- 
jections are  required.  The  injections  are  made  with  an 
all  metal  syringe  capable  of  holding  about  two  ounces 
of  water.  A  moderately  coarse  aspirating  needle  is 
used.  The  syringe  is  filled  with  boiling  water  and  the 
barrel  of  the  syringe  heated  over  an  alcohol  flame  or  a 
Bunsen  burner.  The  patient  is  anesthetized  and  the  eyes 
and  the  skin  surrounding  the  growth  as  well  as  the 
growth  itself  are  anointed  with  sterile  vaseline.  The 
rest  of  the  face  is  covered  with  moist  gauze  to  prevent 
scalding,  as  a  few  drops  of  water  may  escape  from  the 
syringe.  The  syringe  is  held  with  dry  gauze  or  a  dry 
towel.  If  the  gauze  or  towel  is  wet  it  cools  the  syringe 
too  much.  The  needle  should  not  be  too  fine  as  it  would 
make  the  stream  of  water  so  small  as  to  reduce  its  tem- 
perature unduly.  After  plunging  the  needle  into  a 
prominent  portion  of  the  growth,  blood  flows  for  a  few 
seconds,  but  is  readily  controlled  by  the  hot  water.  The 
water  is  injected  rapidly  until  the  tissues  become  tense. 
The  needle  is  then  shoved  to  another  portion  of  the 
growth  and  a  further  injection  given.  Even  in  a  large 
growth  an  effort  should  be  made  to  cover  the  most  promi- 
nent parts  at  the  first  sitting.  If  the  injection  is  made 
too  slowly  the  heat  is  so  reduced  as  to  prevent  its  in- 
jurious effect  upon  the  vascular  endothelium.  Consid- 
erable swelling  follows  for  several  days  and  gradually 
subsides.  No  other  injections  should  be  made  for  ten 
days  or  two  weeks.  If  at  the  end  of  that  time  soft  areas 
show  where  blood-vessels  have  not  been  destroyed,  an- 


TUMORS    OF    BLOOD-VESSELS. 


201 


Fig.    75. 
Fig.   76. 


Fig.   75.  Fig.   76. 

Photograph   of   a   boy,    J.    P.,   thirteen   months  old  with   a   large   angioma   of 

the   nose   which   was   growing   rapidly. 
Another  view  of  the   angioma  of  boy  shown  in  Fig.    75. 


Fig.   77. — A   photograph   of   J.    P.    about   eighteen   months   later   after   a   series   of   in- 
jections  of   hot  water  by  the  method  of  Wyeth. 


262  SURGERY    OF    THE    BLOOD-VESSKLS. 

other  treatment  can  be  given.  The  patient  should  then 
wait  for  at  least  a  month  before  further  injections,  as 
the  injurious  effect  of  the  anesthetic,  together  with  the 
absorption  of  the  products  of  the  injured  cells  are  too 
irritating  to  permit  treatments  in  rapid  succession. 

The  author  has  used  this  method  successfully  in  sev- 
eral angiomas  of  the  face  and  in  a  large  angioma  of  the 
umbilical  region.  The  accompanying  photographs  of  a 
little  boy  show  the  results  of  injection  of  hot  water  in  a 
large  cavernous  angioma  of  the  nose.  About  fifteen  in- 
jections were  made  extending  over  a  period  of  eighteen 
months  (Figs.  75,  76  and  77). 

There  is  but  little  danger  from  emboli  if  the  injection 
is  made  quickly,  for  the  large  blood  cavities  will  rapidly 
form  clots  that  are  too  big  to  enter  a  small  vessel.  The 
usual  antiseptic  precautions  should  be  taken,  but  the 
sterilizing  effect  of  hot  water  is  sufficient  to  insure 
against  septic  clots.  Sometimes  if  the  skin  is  very  thin 
it  may  slough.  The  heat  often  produces  a  blister.  The 
skin  is  dusted  with  boric  acid  or  some  antiseptic  oint- 
ment is  applied  immediately  after  the  injection.  This 
treatment  is  hardly  suitable  for  capillary  angiomas, 
as  these  vessels  are  so  superficial  that  the  heat  neces- 
sary to  destroy  them  may  also  destroy  the  skin.  It  is 
well  suited  for  a  cavernous  or  venous  angioma,  as  the 
hot  water  will  follow  the  various  sinuses  and  vessels  and 
destroy  vessels  that  could  not  be  excised  except  by  tak- 
ing out  a  great  deal  of  healthy  tissue. 

The  old  method  of  running  threads  through  an  angi- 
oma or  leaving  other  foreign  bodies  in  its  substance  has 
been  generally  abandoned.  Not  only  is  it  usually  inef- 
ficient but  small  clots  may  form  which  cause  emboli  and 
the  danger  of  sepsis  is  great. 

Arterial  angioma,  or  cirsoid  aneurism,  which  goes  un- 


TUMORS    OF    BLOOD-VESSELS.  l2()o 

cler  many  names,  is  usually  found  about  the  face  or 
hands.  It  consists  largely  of  masses  of  arteries  that  are 
very  tortuous  and  communicate  with  each  other.  Their 
pulsation  sometimes  causes  erosion  of  the  bone.  Knp- 
ture  of  these  vessels  often  results  in  an  alarming  or 
even  fatal  hemorrhage.  Arterial  angiomas  frequently 
arise  from  small  nevi  and  occasionally  follow  an  injury. 
The  large  vessels  may  become  confluent  and  form  a  cav- 
ity. A  thrill  and  bruit  may  exist  over  the  region  of 
these  angiomas. 

The  treatment  of  such,  a  condition  has  not  been  satis- 
factory. Subcutaneous  ligation  has  been  tried  but  is 
not  often  followed  by  cure.  The  best  treatment  is  liga- 
tion of  the  main  artery  that  supplies  the  aneurism,  as, 
for  instance,  in  cirsoid  aneurism  of  the  forehead  ligation 
of  the  external  carotid.  Often  communications  with 
other  arteries  are  so  large  and  numerous  that  this  is  not 
effective.  Following  the  method  of  Wyeth,  the  artery 
that  directly  opens  into  the  cirsoid  aneurism  can  some- 
times be  dissected  free,  the  central  end  ligated,  and  hot 
water  quickly  injected  into  the  distal  end.  Pressure 
should  be  maintained  around  the  margins  of  the  growth 
to  prevent  a  too  quick  return  of  the  hot  water  into  the 
veins.  The  injection  of  astringents  would  hardly  be 
wise. 


CHAPTER  XV. 

VARICES;  VARICOSE  VEINS,  VARICOCELE, 
AND  HEMORRHOIDS. 

Varicose  veins  are  merely  dilatations  of  previously 
existing  veins  and  so,  of  course,  differ  from  true  tumors 
considered  in  the  previous  chapter,  which  consists  of  new 
growths  composed  of  abnormal  vessels.  Varicose  veins 
of  the  leg  are  more  common  in  the  left  leg  for  the  same 
reasons  that  phlebitis  is  more  frequent  in  the  left  leg 
than  in  the  right.  The  manner  of  the  left  iliac  veins 
crossing  under  the  iliac  arteries,  the  slightly  longer 
course  of  the  left  iliac  vein,  the  pressure  of  the  distended 
sigmoid,  are  all  given  as  factors  that  make  varicose  veins 
in  the  left  leg  more  frequent  than  in  the  right  leg.  The 
pressure  of  a  tumor  or  growth  in  the  pelvis  or  in  the  iliac 
fossa  may  also  be  a  cause  as  well  as  some  defect  in  the 
valves  that  permits  blood  from  the  femoral  vein  to  run 
backward  into  the  saphenous. 

Varicose  veins  are  more  prominent  when  the  patient 
is  standing  and  vary  from  a  slight  dilatation  to  large, 
bluish  masses  that  disappear  on  pressure.  They  are 
always  tortuous  and  in  advanced  cases  extend  from  the 
ankle  to  the  saphenous  opening.  The  veins  sometimes 
vary  in  size,  becoming  larger  or  smaller  at  different 
times.  It  is  quite  common  to  find  varicose  veins  much 
worse  during  pregnancy.  This  is  not  due  solely  to  the 
pressure  of  the  uterus,  because  the  veins  often  begin  to 
enlarge  in  the  first  month  of  pregnancy  before  pressure 
begins.  The  dilatation  may  be  fusiform  or  sacculated 

264 


VARICOSE    VEINS.  ( 

and  only  certain  portions  of  the  saphenous  vein  may  In- 
affected.  The  sluggish  circulation  promotes  clotting 
which  causes  a  still  further  damming  back  of  the  blood 
and  so  increases  the  dilatation  of  the  vein.  The  dan 
gers  of  embolism  from  varicose  veins  are  obvious. 
Sometimes  the  vein  is  so  large  and  thin  that  it  ruptures 
and  serious  hemorrhage  may  occur.  In  the  advanced 
stage  all  the  valves  of  the  saphenous  become  inefficient, 
and  the  long  column  of  blood  has  no  support  except  at  its 
base. 

Trendelenburg  tested  the  efficiency  of  the  valves  by 
elevating  the  leg  for  a  short  time,  stroking  the  blood  to- 
ward the  heart  and  then  compressing  the  saphenous 
trunk.  With  the  saphenous  still  compressed  the  patient 
stands  up  and  the  dilated  veins  below  gradually  fill  with 
blood  from  the  foot  and  leg.  When  the  compression  is 
removed  the  blood  suddenly  rushes  into  the  saphenous 
from  the  femoral  vein.  If,  however,  the  valves  are  ef- 
ficient this  latter  phenomenon  does  not  occur. 

Various  disturbances  arise  due  to  the  obstruction  of 
the  venous  circulation.  The  skin  of  the  leg  and  foot  be- 
comes bluish-red,  infiltrated,  and  liable  to  inflammatory 
affections,  particularly  to  eczema.  The  slightest  injury 
heals  over  with  difficulty  and  ulcers  readily  form.  The 
ankle,  foot,  and  sometimes  the  leg  swell  after  standing 
for  some  time.  In  chronic  cases,  new  connective  tis- 
sue forms  and  produces  a  permanent  thickening.  The 
fat  over  the  veins  disappears  and  the  veins  become  ad- 
herent to  the  skin.  If  a  vein  ruptures  and  a  thrombus 
occurs  the  skin  in  the  immediate  neighborhood  often 
breaks  down  readily.  The  patient  has  muscular  weak- 
ness, and  complains  of  indefinite  pains  and  aching  in  the 
leg  and  foot.  Sciatica  may  occur.  Some  patients  suffer 
a  great  deal,  while  others  apparently  have  but  little  dis- 


266  SURGERY    OF    THE    BLOOD-VESSELS. 

comfort.  The  rupture  of  small  veins  beneath  the  skin 
is  often  followed  by  brownish  pigmentation  of  the  skin. 
This  is  very  common  about  the  ankle.  Inflammation  of 
the  veins  is  readily  accompanied  by  thrombosis.  Bone 
in  the  vicinity  of  the  ulcers  sometimes  becomes  necrotic. 

Varicose  veins  are  very  insidious  in  their  growth  and 
frequently  accompany  diseases  that  either  directly  affect 
the  circulation,  such  as  heart  disease,  or  weaken  the  gen- 
eral resistance  of  the  patient.  It  is  undoubtedly  true 
that  many  families  have  a  tendency  to  varicose  veins. 
Varicose  veins  usually  begin  in  the  small,  superficial 
veins  about  the  middle  of  the  leg,  though  they  may  orig- 
inate from  the  veins  about  the  ankle  or  even  in  the  neigh- 
borhood of  the  knee  joint.  They  are  bluish  or  purplish 
in  color  and  radiate  from  one  spot.  Occasionally,  the 
large  trunks  of  the  leg  or  thigh  are  first  involved.  Some 
authors  claim  that  varicose  veins  originate  in  the  deep 
veins  and  extend  to  the  superficial,  though  this  is  not 
borne  out  by  most  observers.  When  varicose  veins  are 
limited  in  character  they  are  usually  found  where  the 
large  perforating  branches  enter  the  superficial  veins 
from  the  deep  veins. 

There  are  three  forms  of  veins  in  the  lower  extremity ; 
(1)  those  without  valves  in  which  the  blood  may  run 
either  way,  (2)  veins  in  which  the  valves  direct  blood 
toward  the  surface,  and  (3)  those  in  which  the  valves 
direct  the  blood  toward  the  deep  veins.  The  perforating 
branches  are  most  numerous  in  the  middle  and  lower  part 
of  the  leg.  In  the  middle  of  the  leg  they  are  surrounded 
by  muscle  and  these  are  frequently  the  first  to  dilate. 
Often  the  process  extends  from  this  point  to  the  other 
veins.  The  veins  are  elongated  and  become  very  tortu- 
ous and  the  walls  in  the  later  stages  are  thick  from  con- 
nective tissue.  Standing  is  much  more  likely  to  produce 


VARICOSE    VEINS.  1^)7 

varicose  veins  than  walking,  for  the  tension  on  the  mus- 
cles compresses  the  deep  veins  constantly  in  standing, 
whereas  in  walking  or  in  running  there  is  alternate  ten- 
sion and  relaxation  which  serves  to  empty  the  vein. 

The  complications  that  often  occur  are  pigmentation 
of  the  skin,  eczema,  ulceration,  and  neuralgic  pain. 
Some  of  these  complications  are  supposed  to  be  trophic. 
Occasionally  the  pain  may  be  very  severe  and  may  even 
involve  the  sciatic  nerve.  Ulcers  are  difficult  to  heal 
permanently  unless  the  varicose  vein,  which  is  the  cause 
of  the  ulcer,  is  excised.  Club-foot  has  been  mentioned 
as  one  of  the  sequelae  of  varicose  veins  due  to  muscular 
changes  and  to  the  trophic  and  nervous  disturbances. 
This,  however,  must  be  exceedingly  rare. 

The  treatment  of  varicose  veins  may  be  operative  or 
nonoperative.  Nonoperative  treatment  should  be  used 
in  mild  cases.  The  indications  here  are  to  improve  the 
general  health  and  regulate  the  nutrition  and  personal 
hygiene.  Particularly  should  constipation  be  overcome. 
If  an  employment  requires  constant  standing  the  occu- 
pation should  be  changed  or  the  patient  required  to  sit, 
elevating  the  legs  whenever  possible.  In  the  absence  of 
phlebitis  massage  toward  the  heart  is  of  some  value. 
Any  constriction,  such  as  circular  garters  or  tight  bands 
around  the  waist,  should  be  prohibited.  If  the  varicose 
vein  is  localized  and  without  disagreeable  symptoms  no 
other  treatment  is  necessary.  If,  however,  it  tends  to 
extend,  some  form  of  compression  should  be  used. 
Stockings  made  of  rubber  and  silk  are  probably  the  best. 
The  toes  and  the  heel  should  be  left  exposed,  and  the 
stockings  should  not  go  above  the  knee.  Flannel  band- 
ages or  bandages  made  of  some  washable  webbing  that 
can  be  cleaned  and  reapplied  when  necessary  are  cheaper 
and  often  just  as  effective  as  the  most  expensive  elastic 


268  SURGERY    OF    THE    BLOOD-VESSELS. 

stockings.  Any  treatment  depends,  of  course,  upon  the 
cause  of  the  varicose  veins.  If  due  to  heart  disease  elas- 
tic stockings  or  bandages  that  increase  blood  pressure 
are  contraindicated. 

The  operative  treatment  consists  of  ligatures  or  ex- 
cision of  the  veins.  These  two  operations  are  of  very 
ancient  origin,  though  they  have  been  modified  from 
time  to  time.  The  injection  of  astringent  material  into 
the  veins  has  also  been  advocated,  though  it  is  not  prac- 
ticed to  any  extent  at  the  present  day  and  is  undoubt- 
edly liable  to  cause  thrombosis  and  embolism.  The  liga- 
tion  may  be  merely  tying  the  main  trunk  or  using  many 
ligatures  in  such  operations  as  advocated  by  Schede  or 
Friedel.  Schede  completely  encircles  the  leg  with  an  in- 
cision about  the  junction  of  the  upper  and  middle  thirds, 
cutting  all  veins  and  tissues  down  to  the  fascia  of  the 
muscle.  The  veins  are  then  tied  and  the  skin  sutured. 
Friedel  makes  a  spiral  incision  starting  below  the  knee 
and  encircling  the  leg  five  times,  ending  on  the  back  of 
the  foot.  All  veins  are  tied  but  the  wound  is  left  open 
to  drain  away  the  lymph.  Multiple  ligation  of  the  main 
trunk  with  its  branches  has  been  advised,  some  surgeons 
using  as  many  as  thirty  or  forty  ligatures. 

Resection  of  the  saphenous  vein  may  be  partial  as 
recommended  by  Trendelenburg,  who  ligates  and  resects 
the  saphenous  vein  in  three  places,  at  the  middle  of  the 
thigh,  and  above  and  below  the  internal  condyle.  Total 
resection  can  be  done  by  a  long  incision  made  from  the 
saphenous  opening  to  the  posterior  border  of  the  inter- 
nal condyle  and  then  continued  to  the  internal  malleolus. 
If  an  ulcer  is  present  the  incision  does  not  reach  as  far 
as  the  ulcer  so  as  to  avoid  infection.  A  better  method  of 
excision  is  that  recommended  by  C.  H.  Mayo  and  con- 
sists of  multiple  short  incisions  over  the  course  of  the 


VARICOSE    VEINS. 


269 


saphenous  vein  (Fig.  78).  The  vein  is  ligated  and 
stripped  subcutaneously.  This  may  be  done  by  thread- 
ing it  through  a  special  instrument  such  as  has  been  de- 
vised by  Mayo.  The  upper  incision  is  made  just  below 
the  saphenous  opening.  The  vein  is  doubly  tied  and  di- 
vided between  ligatures.  The  lower  end  is  threaded 
through  a  special  instrument  that  resembles  somewhat  a 


Fig.  78. — Method  of  Charles  H.  Mayo  of  stripping  out  varicose  veins  through  mul- 
tiple short  incisions.  Two  special  instruments  for  stripping  veins  are  shown 
at  the  bottom  of  the  illustration. 

blunt  curet.  The  instrument  is  shoved  down  on  the  vein, 
so  stripping  it  from  the  surrounding  tissues  and  tearing 
many  small  branches.  When  the  vein  is  stripped  as  far 
as  possible  in  this  manner  an  incision  is  made  over  the 
elevated  beak  of  the  instrument.  The  vein  is  brought  up 
at  this  point  and  the  instrument  withdrawn  from  the 
first  incision  and  inserted  into  the  second  incision.  The 


270  SURGERY    OF    THE    BLOOD-VESSELS. 

vein  is  again  stripped.  Xo  incision  should  he  made 
on  the  level  of  the  knee  as  the  scar  may  interfere  with 
the  motion  of  the  joint  later  on.  If  the  varicose  veins 
are  extensive,  it  is  impossible  to  strip  them  much  below 
the  knee  as  the  branches  in  this  region  are  large  and 
quite  numerous.  Here  an  incision  may  be  made  either 
curved  or  straight,  so  as  to  expose  the  greatest  number 
of  veins,  which  are  then  excised.  The  methods  of  strip- 
ping the  veins  from  below  upward  are  dangerous  be- 
cause of  the  possibility  of  thrombus  and  embolism.  Bab- 
cock  and  others  have  devised  an  instrument  somewhat 
like  a  long  probe  with  a  bulbous  end,  resembling  a  bougie 
with  a  long  handle.  The  handle  is  inserted  into  the  vein, 
the  bulbous  end  being  too  large  to  enter.  The  handle  is 
cut  down  upon  and  the  vein  in  this  way  turned  wrong 
side  out. 

The  operation  suggested  by  Delbet  of  anastomosing 
the  internal  saphenous  to  the  femoral  vein  at  a  lower 
junction  than  normal  is  hardly  justifiable. 

Varicocele. 

Variococele  is  the  name  applied  to  dilated  veins  in  the 
spermatic  cord.  It  is  common  in  boys  about  fifteen  or 
sixteen  years  of  age  and  in  young  men.  Unfortunately 
quacks  and  advertisers  have  so  exaggerated  the  signifi- 
cance of  this  trouble,  that  many  young  men  have  an  er- 
roneous idea  of  its  importance.  It  is  normal  for  the 
veins  to  enlarge  somewhat  at  certain  times  of  life.  If, 
however,  the  enlargement  is  excessive  the  condition  be- 
comes one  that  should  be  treated.  The  local  signs  and 
symptoms  are  quite  characteristic,  Varicocele  is  more 
frequent  on  the  left  side  than  on  the  right.  This  is  prob- 
ably due  to  the  fact  that  the  left  spermatic  vein  empties 
at  practically  a  right  angle  into  the  left  renal  vein, 


VARICOCELE.  271 

whereas  the  right  spermatic  vein  has  a  shorter  course 
and  empties  obliquely  into  the  vena  cava.  Constipation 
with  a  chronically  filled  signioid  may  also  be  a  causative 
agent  here  as  well  as  in  varicose  veins  of  the  leg1.  If  the 
condition  becomes  aggravated,  the  veins  are  exceedingly 
prominent  and  the  scrotum  is  much  elongated,  particu- 
larly in  warm  weather.  The  veins  resemble  the  old  de- 
scription of  "feeling  like  a  bunch  of  earth  worms." 
Often  there  is  an  impulse  on  coughing,  which  is  not  eas- 
ily confused  with  the  impulse  from  hernia  on  account  of 
the  peculiar  consistency  and  distribution  of  the  varico- 
cele.  When  the  patient  lies  down  the  veins  are  emptied 
and  the  swelling  to  a  large  extent  disappears,  though  in 
old  cases  where  the  walls  of  the  veins  have  thickened 
they  can  be  felt  even  when  the  patient  is  reclining.  If 
the  condition  is  aggravated  and  prolonged,  sometimes 
atrophy  of  the  testicle  occurs  as  a  secondary  change 
from  passive  hyperemia.  Dull  aches  and  a  dragging 
sensation  are  frequently  complained  of.  There  are 
often  various  nervous  symptoms  that  may  merely  ac- 
company, and  not  be  caused  by,  varicocele. 

One  of  the  most  important  things  about  varicocele  is 
its  diagnostic  significance  of  a  tumor  of  the  left  kidney. 
As  the  left  spermatic  vein  empties  into  the  left  renal 
vein,  a  tumor  of  the  left  kidney  that  compresses  the  renal 
vein  is  likely  to  cause  a  left  varicocele.  Varicocele  is  a 
disease  of  youth.  Xo  particular  importance  can  usually 
be  attached  to  its  development  in  the  young.  However, 
in  the  middle  aged  or  old  the  rather  sudden  occurrence 
of  marked  varicocele  on  the  left  side  should  always  at- 
tract the  attention  of  the  surgeon  to  the  possibility  of  a 
tumor  of  the  left  kidney. 

The  treatment  of  varicocele  in  boys  or  young  men 
often  requires  merely  moral  reassurance  that  the  condi- 


272  SURGERY    OF    THE    BLOOD-VESSELS. 

tion  is  not  a  serious  one.  Cold  baths  each  day,  regula- 
tion of  the  bowels,  and  personal  hygiene  should  he  rec- 
ommended. If  the  varicocele  is  marked,  a  snugly  fitting 
suspensory  should  be  advised.  If  the  condition  has  ex- 
isted many  years  and  the  scrotum  is  much  relaxed,  and 
particularly  if  accompanied  by  dragging  or  neuralgic 
pain,  operation  should  be  performed. 

The  operation  consists  either  in  ligation  or  excision 
of  the  veins.  Formerly,  subcutaneous  ligation  was  much 
practiced,  but  this  operation  has  justly  fallen  into  dis- 
repute. Ligation  should  be  done  through  an  open  in- 
cision, which  may  be  high  in  the  upper  part  of  the  scro- 
tum and  lower  portion  of  the  inguinal  canal,  or  low  down 
about  the  center  of  the  scrotum.  'When  the  scrotum  is 
not  shortened  the  high  operation  offers  many  advan- 
tages. The  incision  is  about  two  inches  long,  its  upper 
end  corresponding  to  the  external  inguinal  ring.  The 
structures  of  the  cord  are  freed  and  drawn  into  the 
wound.  The  vas  is  recognized  by  its  denseness,  feeling 
like  a  wire  or  whip-cord.  The  vas  should  be  separated 
with  a  few  veins  and  the  spermatic  artery  from  the  rest 
of  the  cord  and  held  aside  by  a  piece  of  gauze.  Care 
should  be  taken  not  to  bruise  the  vas  by  strong  traction 
or  by  catching  it  with  forceps.  The  rest  of  the  veins  and 
tissues  of  the  .cord  are  then  ligated  close  to  the  upper 
angle  of  the  incision,  using  catgut.  The  ligatures  are 
tied  very  tightly,  preferably  holding  the  first  turn  of  the 
knot  with  forceps  while  the  second  turn  is  run  down. 
Two  ligatures  are  applied  about  one-fourth  of  an  inch 
from  each  side.  The  ends  of  the  lower  ligature  are  left 
long.  A  sufficient  amount  of  the  veins  is  pulled  up  to 
draw  the  testicle  well  up  from  the  bottom  of  the  scrotum. 
Two  ligatures  are  applied  at  the  lower  end  in  the  same 
manner  as  the  upper  end.  The  intervening  segment  of 


VARICOCELE. 

veins  is  excised  and  the  two  venous  stumps  tied  together 
by  the  long  ends  of  the  ligatures.  Each  bleeding  spot  is 
tied  and  the  wound  closed  without  drainage.  A  sus- 
pensory bandage  should  be  worn  for  some  months  after 
the  operation.  A  hard  mass  around  the  ligatures  may 
exist  for  a  month  or  more. 

As  a  rule,  when  an  operation  for  varicocele  is  indi- 
cated, the  scrotum  should  be  resected.  A  relaxed  scro- 
tum that  does  not  afford  support  to  the  testicle  but  per- 
mits the  testicle  to  dangle  from  shortened  cords  will  not 
give  an  ideal  result.  Most  varicoceles  are  accompanied 
by  relaxed  scrotums,  so  the  operation  should  be  devised 
to  accomplish  both  the  resection  of  the  veins  and  short- 
ening the  scrotum.  If  a  transverse  incision  is  made,  its 
two  ends  form  projecting  points  or  teats,  which  fre- 
quently become  irritated,  and  the  scar  is  always  wide. 
A  better  plan  is  to  resect  the  scrotum  along  the  middle 
line,  parallel  with  the  median  raphe.  As  much  of  the 
scrotal  tissue  as  should  be  removed  is  taken  up  and 
clamped  with  one  or  two  pairs  of  curved  pedicle  forceps. 
This  redundant  scrotum  is  then  cut  away  with  a  sharp 
knife  or  scissors  on  the  proximal  side  of  the  clamp,  so 
as  to  leave  no  bruised  tissue  for  healing.  This  should 
be  done  quickly  and  the  bleeding  points  all  carefully 
clamped,  otherwise  they  retract  and  leave  a  hematoma. 
After  they  have  been  clamped  and  tied  with  fine  catgut, 
the  cord  is  dissected  free  and  the  vas  deferens  is  isolated 
with  a  few  veins  and  the  spermatic  artery.  Gessner,  of 
New  Orleans,  has  recently  shown  experimentally  that  if 
the  spermatic  artery  is  tied  the  testicle  eventually  be- 
comes functionless.  The  excessive  length  of  the  veins 
is  then  resected  as  described  above,  the  testicle  being- 
elevated  by  tying  together  the  ends  of  the  ligatures 
of  the  stumps.  The  scrotum  is  sutured  with  a  con- 


274  SURGERY    OF    THE    BLOOD-VESSELS. 

tinuous  mattress  stitch  of  medium  catgut.  The  mat- 
tress suture  prevents  the  turning  in  of  the  margins  of 
the  scrotum.  It  is  best  to  reenforce  this  with  a  few  in- 
terrupted sutures  of  silkworm  gut,  for  catgut  may  be  ab- 
sorbed too  soon.  The  incision  is  closed  in  such  a  man- 
ner as  to  simulate  the  median  raphe.  If  each  bleeding 
point  is  tied  there  is  no  necessity  for  drainage.  The 
wound  is  dressed  in  the  usual  way  with  sterile  gauze  held 
in  position  by  adhesive  plaster  and  a  sling  or  suspensory 
bandage.  The  patient  should  be  in  bed  about  a  week 
and  should  wear  a  snugly  fitting  suspensory  bandage  for 
two  or  three  weeks  longer.  This  operation  not  only  does 
away  with  the  veins,  but  also  has  the  advantage  of  con- 
verting the  scrotum  into  a  support  for  the  testicles  and 
thus  obviates  the  necessity  of  constantly  wearing  a  sus- 
pensory bandage. 

Hemorrhoids. 

Hemorrhoids,  or  piles,  are  dilated  or  abnormal  veins 
or  capillaries  that  form  in  the  lower  part  of  the  rectum 
or  in  the  anus,  and  are  accompanied  by  excessive  con- 
nective tissue  and  thickening  of  the  coats  of  the  vessels 
involved. 

The  predisposing  causes  may  be  regarded  as,  first,  the 
upright  position;  second,  the  absence  of  valves  in  the 
portal  vein ;  third,  the  manner  in  which  the  muscular  coat 
of  the  rectal  wall  is  perforated  by  veins;  and,  fourth, 
the  lack  of  a  proper  support  for  the  blood-vessels  in  this 
locality  as  the  mucous  membrane  is  very  loosely  attached 
to  the  submucous  coat.  The  damming  back  of  blood  in 
the  portal  vein,  into  which  empties  the  superior  hemor- 
rhoidal,  is  as  constant  in  sitting  as  in  standing.  The 
length  of  the  column  of  blood  must  be  measured  from  the 
lowest  extremity  of  the  rectum  to  the  entrance  of  the 


HEMORRHOIDS. 

portal  vein  into  the  liver  and  is  about  fourteen  indie 
Unlike  varicose  veins  in  the  extremities,  the  sitting 
ture  offers  no  relief,  but  on  the  contrary  may  tend  to 
promote  further  congestion  of  the  hemorrhoidal  veins,  as 
bending  the  body  and  pressure  on  the  liver  increase  the 
pressure  in  the  portal  circulation. 

In  some  families  there  is  a  hereditary  tendency  toward 
hemorrhoids.  Constipation,  excesses  in  diet,  straining 
at  stool  are  causes.  Diseases  of  the  heart,  liver,  or 
kidneys  produce  hemorrhoids,  particularly  diseases  of 
the  liver  that  cause  partial  obstruction  of  the  portal  vein. 
One  of  the  most  significant  signs  of  malignancy  in  the 
large  bowel,  especially  in  the  sigmoid,  is  the  presence  of 
hemorrhoids.  When  severe  hemorrhoids  appear  in  the 
middle  aged  or  elderly  without  apparent  cause  it  should 
always  create  a  suspicion  of  cancer  of  the  colon  or  sig- 
moid, as  the  contraction  from  cancer  or  pressure  of  a 
malignant  tumor  may  dam  back  the  blood  in  the  lowest 
portion  of  the  portal  circulation. 

Hemorrhoids  are  classed  as  external,  internal,  or 
mixed.  External  hemorrhoids  arise  as  a  rule  from  the 
inferior  hemorrhoidal  vein  and  are  external  to  the 
sphincter.  They  may  give  but  little  trouble.  If  they 
become  inflamed  the  pain  will  be  considerable  and  they 
should  be  removed.  Often  small  thrombi  occur.  As  the 
result  of  old  thrombi  or  inflammation  in  external  hemor- 
rhoids, tags  or  projections  of  connective  tissue  some- 
times form. 

The  most  frequent  kind  of  external  hemorrhoids  is  the 
thrombotic  pile.  This  usually  comes  suddenly  from  ex- 
ertion, and  particularly  after  straining  at  stool.  The 
thrombus  may  be  due  to  breaking  the  inthna  of  the  vein, 
which  permits  its  lumen  to  be  filled  with  clots,  or  to  a 
rupture  of  the  vein  itself  and  the  formation  of  a 


276  SURGERY    OF    THE    BLOOD-VESSELS. 

hematoma  in  the  surrounding  tissues.  The  size  of  a 
thrombotic  hemorrhoid  varies  from  one-eighth  to  one 
inch  in  diameter.  Usually  there  is  a  feeling  of  some- 
thing giving  away  followed  by  aching.  After  a  few 
hours  or  a  day,  as  the  clot  hardens,  the  sensation  be- 
comes much  more  disagreeable  and  the  aching  and  burn- 
ing may  be  excessive.  If  the  clot  is  very  small,  the 
symptoms  are  often  insignificant. 

The  only  treatment  that  affords  real  relief  is  incision 
and  turning  out  the  clot.  This  can  be  done  under  local 
anesthetic,  using  a  half  of  one  percent  novocaine  solu- 
tion. After  cleansing  the  mucous  membrane  and  the 
skin,  the  tissue  over  the  thrombus  is  injected  and  an  in- 
cision made  down  to  the  clot.  No  matter  how  the  throm- 
bus is  situated,  the  incision  should  radiate  from  the  cen- 
ter of  the  anus  so  as  to  be  parallel  with  the  normal  folds. 
The  clot  is  removed  and  the  cavity  packed  lightly  with 
gauze,  which  is  kept  in  position  one  or  two  days.  Par- 
ticular care  should  be  taken  to  cleanse  the  anus  thor- 
oughly with  soap  and  water  after  each  bowel  movement. 
If  the  clots  are  multiple  and  small,  the  tissue  containing 
them  may  be  excised.  The  sphincter  should  not  be  cut. 
Usually,  however,  they  are  either  single  or  so  large  that 
each  clot  can  be  opened  by  a  separate  incision. 

If  the  clots  are  left  they  may  be  absorbed,  but  more  fre- 
quently they  become  organized  into  connective  tissue,  or 
even  calcined,  and  prove  a  constant  source  of  irritation. 
Sometimes  the  clot  is  infected  and  an  abscess  occurs. 

Operations  about  the  anus  heal  quickly  if  the  ordinary 
rules  of  cleanliness  and  antiseptic  surgery  are  followed, 
even  though  it  is  necessarily  difficult  or  impossible  to 
render  the  parts  surgically  clean.  Nature  has  appar- 
ently provided  some  immunity  against  infection  for  the 
tissues  here,  else  wounds  would  be  always  infected. 


HEMORRHOIDS.  2/7 

Internal  hemorrhoids  are  usually  venous,  but  may  con- 
sist of  a  capillary  growth  which  is  small,  resembling 
a  raspberry,  and  bleeds  easily,  as  it  is  covered  by  a 
very  thin  layer  of  epithelium.  Capillary  hemorrhoids 
do  not  protrude  and  can  hardly  be  located  by  touch. 
They  constitute  what  is  known  as  the  blind,  bleeding 
pile,  and  bleed  readily  upon  slight  contact  of  instru- 
ments on  examination.  As  a  rule,  the  amount  of  blood 
lost  is  never  great  but  the  frequent  bleeding  soon  pro- 
duces marked  anemia.  The  best  treatment  for  this 
type  of  hemorrhoid  is  cauterization,  which  may  be  done 
through  a  speculum  with  a  Paquelin  or  electric  cautery. 

The  most  frequent  form  of  internal  hemorrhoids  is 
that  which  develops  from  the  superior  hemorrhoidal  vein 
just  within  the  sphincter.  Often  the  first  symptom  is 
slight  oozing  of  blood;  later,  there  is  some  protrusion. 
Bleeding  may  recur  from  time  to  time  and  may  be  very 
slight.  This  varicose  condition  is  increased  by  anything 
that  raises  the  blood  pressure  in  the  lower  part  of  tho 
rectum.  Constipation  or  irregular  diet  will  often  cause 
it.  Frequently  there  is  no  pain  except  when  there  is 
protrusion,  and  then  it  is  more  a  sense  of  discomfort. 
There  is  often  present,  however,  a  constant  sense  of 
weight  and  dull  aching  in  the  region  of  the  rectum.  Dig- 
ital examination  will  disclose  the  smooth,  velvety  feel  of 
partly  collapsed  hemorrhoids.  Reflex  nervous  symp- 
toms may  occur,  particularly  in  patients  who  are  in- 
clined to  be  neurotic. 

Treatment  of  internal  venous  and  of  mixed  hemor- 
rhoids is  practically  the  same.  If  bleeding  is  frequent 
and  if  discomfort  is  considerable,  operation  should  be 
performed.  However,  palliative  treatment  sometimes 
cures  in  the  early  stages  when  the  disease  is  mild  and 
if  for  any  reason  the  patient  rejects  operation,  palliative 


278  SURGERY    OF    THE    BLOOD-VESSELS. 

treatment  should  be  given.  Rest  in  the  horizontal  posi- 
tion and  cold  applications  are  very  beneficial.  Often 
pressure  on  the  anus  is  effective.  In  order  to  lessen  the 
congestion  in  internal  hemorrhoids,  it  is  necessary  to 
change  the  position  of  the  body  so  the  portal  circulation 
will  easily  drain  the  blood  from  the  pelvis.  A  slight  ele- 
vation of  the  foot  of  the  bed  may  be  necessary.  Enemas 
of  cold  water  and  careful  regulation  of  the  bowels  should 
be  recommended.  Alcohol  must  be  prohibited  or  cur- 
tailed in  amount.  The  patient  must  take  some  exercise 
in  the  open  air  and  the  bowels  be  induced  to  move  at  a 
regular  time  every  morning.  Cold  baths  after  arising 
are  beneficial.  If  the  bowels  are  constipated,  mild  ca- 
thartics such  as  cascara  are  given.  If  hemorrhoids  tend 
to  prolapse,  they  should  be  cleansed  thoroughly  before 
being  returned  and  some  ointment  or  solution  applied. 
Suppositories  are  not  satisfactory  because  they  slip  above 
the  region  of  the  hemorrhoid.  Occasionally  passage  of  a 
rectal  bougie  of  full  size  once  a  day  and  allowing  it  to 
remain  in  the  grasp  of  the  sphincter  for  five  or  ten  min- 
utes will  overcome  spasm. 

Operative  treatment,  which  should  be  the  regular  treat- 
ment for  hemorrhoids  that  develop  sufficiently  to  give 
considerable  discomfort,  may  be  the  injection  method, 
ligature,  excision,  or  clamp  and  cautery.  The  injection 
method  formerly  had  considerable  vogue  but  has  now 
rather  fallen  into  disrepute.  In  certain  cases,  however, 
where  there  are  only  one  or  two  isolated  hemorrhoids 
and  when  the  sphincter  is  relaxed,  the  injection  method 
if  properly  used  often  gives  satisfactory  results.  The 
size  of  the  hemorrhoid  is  no  contraindication  to  this 
operation.  Formerly  too  strong  a  solution  was  used 
and  very  disagreeable  results  would  follow.  Tuttle's 
modification  of  Shuford's  solution  is  probably  the  best. 


HEMORRHOIDS.  -<:' 

This  consists  of  two  drams  of  Calvert's  carbolic  acid, 
one-half  dram  of  salicylic  acid,  one  dram  of  biborate  of 
soda,  and  glycerine,  a  sufficient  quantity  to  make  one 
ounce.  The  fluid  should  be  perfectly  clear.  It'  milky 
white  it  is  due  to  imperfect  solution  and  should  not  In- 
used  until  it  becomes  perfectly  clear.  The  amount  of 
this  solution  to  be  injected  into  any  individual  hemor- 
rhoid  depends  upon  the  size;  from  two  to  ten  minims  are 
sufficient.  The  injection  can  be  made  with  the  ordinary 
hypodermic  syringe.  The  anus  is  cleansed  and  the  hem- 
orrhoid  drawn  down  into  view.  The  index  finger  of  the 
left  hand  is  introduced  into  the  anus  and  a  hypodermic 
needle  is  inserted  at  the  lowest  part  of  the  hemorrhoid 
and  carried  well  toward  its  center.  A  small  amount  of 
the  solution  is  slowly  injected  while  moving  the  point 
of  the  needle  backward  and  forward  to  distribute  the 
injected  fluid.  The  needle  is  left  in  position  for  one  or 
two  minutes  to  prevent  the  solution  escaping  from  the 
puncture,  and  is  then  withdrawn.  A  small  piece  of  cot- 
ton soaked  in  alcohol  is  placed  over  the  puncture  imme- 
diately after  the  needle  is  withdrawn.  The  hemorrhoid 
is  kept  outside  the  sphincter  for  a  few  minutes  in  order 
to  prevent  forcing  the  solution  elsewhere.  After  it  is 
reduced  a  small  compress  is  placed  upon  the  anus,  se- 
cured by  a  T-bandage,  and  the  patient  is  required  to  lie 
down  for  ten  or  fifteen  minutes.  The  day  after  the  in- 
jection the  pile  will  be  found  to  consist  of  a  tense,  hard 
mass  which  in  a  few  days  begins  to  shrivel,  and  if  the 
treatment  is  successful  it  eventually  disappears.  There 
is  but  little  pain  if  the  injection  is  properly  done.  The 
bowels  should  be  confined  for  forty-eight  hours  and  then 
moved  with  a  simple  laxative  or  a  cold  water  enema. 
A  great  many  cases  can  be  cured  in  this  manner  at  the 
office  that  would  not  submit  to  a  more  radical  procedure. 


280  SURGERY    OF    THE    BLOOD-VESSELS. 

While  this  method  should  only  be  employed  when  the 
sphincter  is  weak  and  when  there  are  only  one  or  two 
hemorrhoids,  and  while  it  does  not  always  result  in  a 
cure,  it  has  a  field  of  usefulness. 

Before  an  operation  for  hemorrhoids,  the  patient's 
bowels  should  be  thoroughly  moved  by  a  dose  of  oil  taken 
the  day  before  and  by  an  enema  five  or  six  hours  before 
the  operation.  Before  applying  any  operative  proced- 
ure except  injection,  the  sphincter  must  be  thoroughly 
dilated.  This  is  best  done  with  the  finger  and  thumb, 
gently  stretching  and  massaging  the  sphincter  so  its 
paralysis  is  gradually  accomplished.  In  this  way  neither 
the  sphincter  nor  the  mucous  membrane  is  torn,  which 
is  often  the  case  with  too  forcible  dilatation.  In  the 
ligature  operation,  after  cleansing  the  hemorrhoid  thor- 
oughly and  using  some  antiseptic  solution,  such  as  boric 
acid  or  weak  bichloride,  the  pile  is  caught  in  forceps  and 
an  incision  made  with  scissors  at  Hilton's  white  line 
where  the  skin  and  mucous  membrane  join.  The  pile  is 
dissected  from  below  upward,  partly  with  scissors  and 
partly  with  dry  gauze,  using  as  little  force  as  possible, 
and  getting  the  pedicle  down  to  a  small  piece  of  tissue. 
The  pedicle  is  tied  firmly  with  silk  or  linen  and  the  hem- 
orrhoid cut  off  not  too  close  to  the  ligature.  Each  pile 
is  treated  in  a  similar  manner.  This  can  often  be  done 
under  local  anesthesia. 

The  excision  operation,  which  is  based  upon  the 
method  of  Whitehead,  has  been  variously  modified,  and 
consists  of  excision  of  the  pile  bearing  area.  An  inci- 
sion is  made  around  the  anus  following  closely  Hilton's 
white  line.  The  mucous  membrane  is  dissected  up  until 
all  of  the  piles  can  be  drawn  down  without  tension.  The 
whole  lower  cuff  of  the  pile  bearing  area  of  mucous  mem- 
brane is  excised  by  cutting  a  short  distance  and  immedi- 


HEMOERHOIDS.  1_N  ] 

ately  suturing.  This  prevents  retraction  of  the  mucous 
membrane.  Tuttle  has  modified  this  operation  by 
merely  making-  an  incision  at  the  posterior  portion  <>r 
Hilton's  line  and  then  bluntly  dissecting  free  the  mucous 
membrane  from  this  incision.  There  are  many  ot  I  id- 
methods  of  excision.  In  Earle's  operation  the  pile  is 
clamped  by  special  forceps  of  his  device.  It  is  cut  away 
and  sutures  are  placed  around  the  forceps  including  tin- 
pedicle  of  the  pile.  After  the  sutures  are  placed  tin- 
forceps  are  removed  and  the  sutures  tied.  In  any 
method  the  skin  should  not  be  caught,  as  it  is  unneces- 
sary and  makes  convalescence  much  more  painful. 

The  most  satisfactory  operation,  as  a  rule,  for  hemor- 
rhoids and  one  that  has  well  stood  the  test  of  time  is  the 
clamp  and  cautery.  If  carefully  performed  it  should 
not  result  in  stricture.  Ligature  methods  are  followed 
by  a  certain  amount  of  necrosis  and  in  excision  the  su- 
tures must  necessarily  be  bathed  in  fecal  contents,  but 
the  great  advantage  of  the  clamp  and  cautery  is  that  the 
heat  sterilizes  the  tissues  and  also  seals  the  wound  with 
an  aseptic  eschar.  The  operation  is  simple,  though  it 
should  be  carefully  done  in  order  to  secure  the  best  re- 
sults. After  thoroughly  dilating  the  sphincter  each 
hemorrhoid  is  caught  at  its  apex  with  a  hemostat.  It  is 
dragged  well  down  into  the  wound  and  clamped  with 
Ferguson's  pedicle  forceps  parallel  with  the  anal  folds. 
These  forceps  have  blades  that  are  flat  and  hold  the  hem- 
orrhoid firmly.  No  skin  should  be  included  within  the  bite 
of  the  forceps.  It  is  best  not  to  make  an  incision  with 
scissors  or  knife  because  this  leaves  a  raw  surface  that 
may  be  a  portal  of  infection.  The  object  of  the  clamp 
and  cautery  operation  should  be  to  leave  nothing  that 
is  not  thoroughly  covered  with  an  eschar.  With  a  little 
care  a  good  hold  can  be  obtained  upon  the  hemorrhoid 


282 


SURGERY    OF    THE    BLOOD-VESSELS. 


without  including  the  skin.  All  of  the  hemorrhoids  are 
caught  with  Ferguson's  clamps  in  a  similar  manner. 
There  are  rarely  more  than  three.  After  all  the  piles 
have  been  clamped,  the  last  one  clamp<  d  is  pulled  down 
so  the  tip  of  the  Ferguson  forceps  emerges  from  the 


Fig.  79. — Three  hemorrhoids  have  been,  clamped  with  Ferguson  forceps,  two  having 
been,  cut  away  while  the  third  is  still  in  the  grasp  of  the  forceps.  Each  for- 
ceps should  be  surrounded  by  wet  gauze  and  the  base  of  the  hemorrhoids 
thoroughly  cauterized. 

anus.  A  small  piece  of  wet  gauze  is  wrapped  around  the 
base  of  the  hemorrhoid  just  beneath  the  forceps.  This 
protects  the  surrounding  tissues  from  heat.  The  pile  is 
cut  off  about  one-fourth  of  an  inch  from  the  forceps. 
This  can  be  done  with  the  Paquelin  cautery.  The  stump 


HEMORRHOIDS.  283 

is  then  thoroughly  burned,  taking  at  least  one-half  min- 
ute in  order  that  the  pedicle  contained  in  the  grip  of  the 
forceps  is  cooked  by  the  heat.  The  wet  gauze  is  then 
removed  and  the  next  hemorrhoid  is  treated  in  a  similar 
way.  After  cauterizing  the  hemorrhoid,  the  forceps  are 
not  removed  but  are  merely  returned  to  such  a  position 
as  is  least  in  the  way.  This  is  usually  accomplished  by 


Fig.  80. — Hemorrhoids  have  been  removed,  the  pedicles  cauterized,  and  the  forceps 
have  been  replaced  within  the  anus.  The  rubber  tube  is  in  position.  The 
forceps  can  now  be  gently  released  without  disturbing  the  eschar. 

placing  the  tip  of  the  forceps  in  the  rectum  and  shoving 
the  pedicle  in  its  grasp  gently  up  into  the  rectum  (Figs. 
79  and  80).  After  the  last  hemorrhoid  is  cauterized  a 
rather  firm  rubber  tube  about  three  inches  long  and  one- 
third  of  an  inch  in  diameter  is  anointed  with  sterile 
vaseline  and  inserted  into  the  rectum.  A  safety  pin  is 
fixed  in  its  outer  end.  Then  each  Ferguson  clamp  is 
removed  gently  so  as  to  avoid  breaking  up  the  eschar. 


284  SURGERY    OF    THE    BLOOD-VESSELS. 

The  parts  are  thoroughly  dusted  with  bicarbonate  of 
soda  and  sterile  gauze  is  wrapped  around  the  outer  end 
of  the  tube  under  the  safety  pin  to  prevent  the  safety  pin 
from  pressing  on  the  anus.  More  gauze  is  placed  and  a 
T-bandage  applied.  If  care  is  taken  in  the  cauterization 
as  has  been  mentioned,  there  is  practically  no  danger  of 
hemorrhage  because  the  tissue  is  cooked  well  down  into 
the  grasp  of  the  forceps.  There  is  no  danger  of  stricture 
because  an  ample  amount  of  healthy  mucosa  is  between 
each  forceps,  and  at  the  same  time  the  contraction  of  the 
scar  from  the  burn,  which  is  notoriously  greater  than 
from  an  incision,  tends  to  obliterate  still  further  any 
varicose  vessels  in  the  neighborhood.  The  tube  gives 
exit  for  gas  and  makes  the  patient  more  comfortable. 
If  for  any  reason  there  is  bleeding,  it  will  appear  at  once 
through  the  tube. 

The  after-treatment  consists  of  rest  in  bed  for  sev- 
eral days,  preferably  three  or  four  days  at  least,  and 
morphine  if  the  pain  is  severe.  About  the  third  day 
after  operation  an  enema  of  several  ounces  of  sweet 
oil  is  injected  through  the  tube  and  the  tube  clamped 
and  allowed  to  come  away.  The  skin  around  the  anus 
should  be  kept  clean.  If  there  is  noi  much  irritation  a 
dry  dusting  powder  is  used.  If  the  irritation  is  disa- 
greeable, some  ointment  or  carbolated  vaseline  can  be 
applied.  The  bowels  should  move  regularly  after  the 
third  day.  A  laxative  is  given  in  order  to  insure  that 
the  movements  will  be  soft.  The  patient  may  leave  the 
hospital  within  a  week  or  ten  days,  or  in  the  simpler 
cases  even  earlier.  There  is  always  swelling  for  the 
first  few  days  after  an  operation  of  this  type  and  the  pa- 
tient should  be  informed  before  the  operation  that  this 
will  occur.  The  swelling  gradually  disappears  and  the 
redundant  tissue  is  usually  taken  up  within  a  few  weeks 


HEMORRHOIDS.  -IS.") 

or  at  least  a  few  months.  If,  however,  any  unnecessary 
tags  of  skin  are  left  after  several  months  they  may  lie 
readily  removed  under  a  local  anesthetic. 

A  great  many  rectal  operations  are  done  under  local 
anesthesia,  even  the  clamp  and  cautery  operation.  The 
sphincter  can  be  dilated  and  a  ligature  applied  in  pa- 
tients who  are  not  too  nervous.  The  anesthetic  should 
be  one-half  of  one  percent  novocaine  solution.  ( hie  finder 
is  passed  into  the  anus  and  the  hypodermic  needle  in- 
serted first  about  one  inch  back  of  the  posterior  margin 
of  the  anus.  The  solution  is  injected  quickly,  the  needle 
being  carried  up  first  on  one  side  and  then  on  the  other 
and  the  injection  made  just  beneath  the  skin  and  not  into 
it.  The  point  of  the  needle  is  guided  partly  by  the  fin- 
ger in  the  rectum.  Both  sides  are  injected  from  the 
same  puncture.  After  as  much  tissue  has  been  infil- 
trated as  possible,  the  needle  is  withdrawn  and  rein- 
serted at  the  upper  limit  of  the  injected  area  first  on  one 
side  and  then  on  the  other  until  the  anus  is  completely 
surrounded.  The  injection  may  then  be  made  somewhat 
deeper.  It  will  be  found  that  in  many  cases  the  sphinc- 
ter can  be  dilated  and  hemorrhoids  excised  after  local 
anesthesia  of  this  type  with  practically  no  pain. 


CHAPTER  XVI. 

TRANSPLANTATION  OF  TILE  ANTERIOR 
TEMPORAL  ARTERY. 

Occasionally  defects  of  the  cheek,  caused  by  accidents, 
or  as  a  result  of  operation  for  malignant  disease,  or  from 
a  gangrene,  are  so  extensive  that  plastic  correction 
is  exceedingly  difficult.  The  margins  of  the  defect  are 
fixed  to  the  bone  and  do  not  permit  much  stretching.  If 
flaps  are  taken  from  the  arm,  the  character  and  texture 
of  the  skin  is  so  different  from  the  skin  of  the  face  that 
the  contrast  is  very  noticeable.  Then,  too,  it  is  fre- 
quently necessary  to  have  an  epithelial  lining  on  the  in- 
side of  the  mouth,  and  though  a  mucous  membrane  lining 
is  preferable  to  one  of  skin,  it  is  often  impossible  to  se- 
cure' mucous  membrane. 

Flaps  from  the  forehead  are  used  to  remedy  these  de- 
fects, and  are  taken  with  the  pedicle  either  from  the  tem- 
poral region  or  from  the  middle  of  the  forehead.  This, 
of  course,  necessitates  cutting  the  pedicle  later  and  re- 
turning it  to  its  original  position.  If  the  anterior  tern 
poral  artery  is  included  in  the  pedicle,  the  flap  is  thus  de- 
prived of  an  important  blood  supply.  Frequently  flaps 
that  cover  defects  of  the  cheek  obtain  their  sole  nourish- 
ment around  the  edges,  and  if  a  flap  has  also  been  turned 
in  to  make  a  lining,  there  is  a  still  greater  demand  upon 
the  external  flap  for  blood  supply.  Dunham,  of  New 
York,  has  met  this  objection  by  dissecting  the  temporal 
artery  from  the  flap  after  the  flap  has  healed  in  its  new 
position  and  returning  the  pedicle  minus  the  artery. 
This,  of  course,  is  an  improvement,  but  it  necessitates 

286 


TRANSPLANTATION    OF    ANTERIOR    TEMPORAL    AKTI.HY.         "2^1 

two  operations  and  the  dissection  of  the  temporal  artery 
from  the  transposed  and  infiltrated  pedicle  is  more  diffi- 
cult than  a  dissection  from  the  normal  tissue  at  the 
original  operation. 

On  two  occasions  the  author  has  transplanted  the  an- 
terior temporal  artery,  dissecting*  it  free  from  its  origin 
to  the  margin  of  the  proposed  flap. 

The  anterior  temporal  artery  presents  peculiar  ad- 
vantages for  transplantation.  It  is  not  essential  to  the 
nourishment  of  the  forehead  or  scalp,  which  has  an  abun- 
dant anastomosing  blood  supply.  It  is  tortuous  and 
when  dissected  free,  even  with  some  surrounding  tissue, 
it  may  be  straightened  and  will  reach  much  farther  than 
before  dissection.  This  permits  placing  the  flap  in  posi- 
tions distant  from  the  origin  of  the  artery,  and  the  main- 
tenance of  an  abundant  blood  supply. 

The  patient  should  be  prepared  for  rectal  anesthesia 
according  to  the  method  of  Gwathmey.  The  bowels  are 
opened  by  a  dose  of  oil  the  night  before,  followed  by 
soap  sud  enemas  two  to  three  hours  before  the  operation. 
An  hour  before  the  operation  a  suppository  of  five  to 
ten  grains  of  chlorotone  is  given.  A  hypodermic  of  a 
quarter  of  a  grain  of  morphine  and  l/120th  of  a  grain 
of  atropine  is  administered  a  half  hour  before  the  opera- 
tion, and  the  injection  of  oil  and  ether  is  begun  slowly 
about  ten  minutes  later.  The  mixture  consists  of  pure 
olive  oil  and  ether  varying  from  equal  parts  in  children, 
to  three  parts  of  ether  and  one  of  oil  in  cases  difficult  to 
anesthetize.  In  adults,  usually  two  parts  of  ether  to  one 
of  olive  oil  is  a  satisfactory  mixture.  The  amount  in- 
jected is  one  ounce  of  the  mixture  to  every  twenty  pounds 
of  body  weight,  but  in  any  case  it  should  not  exceed  eight 
ounces  of  the  seventy -five  percent  solution  of  ether  in  oil. 
This  is  given  slowly  in  the  room,  with  the  patient  turned 


288 


SURGERY    OF    THE    BLOOD-VESSELS. 


on  liis  left  side,  and  should  take  from  five  to  ten  minutes. 
The  patient  usually  goes  under  the  anesthetic  gradually. 
If  anesthesia  seems  too  profound,  especially  as  indicated 
by  cyanosis  and  disturbance  of  the  respiration  or  by  a 


Fig.  81. — First  step  of  transplantation  of  the  anterior  temporal  artery  with  a 
frontal  flap.  Outlines  of  the  flap  on  the  neck  and  of  the  frontal  flap,  together 
with  the  incisions  for  dissecting  out  the  anterior  temporal  artery,  and  for 
burying  it  in  its  new  location  are  shown. 

bad  pulse,  some  or  all  of  the  mixture  can  be  withdrawn 
through  a  rectal  tube.  About  five  minutes  before  the 
operation  is  concluded  all  of  the  mixture  is  withdrawn, 
the  rectum  and  sigmoid  are  irrigated  with  cold  water,  and 
several  ounces  of  pure  olive  oil  are  slowly  injected  and 
allowed  to  remain.  This  anesthesia  in  the  author's 


TRANSPLANTATION    OF    ANTEEIOR    TEMPORAL    ARTKKY.         L'SD 

hands  has  been  most  satisfactory  for  surgery  of  the  neck, 
for  plastic  work  about  the  face,  and  particularly  for 
such  an  operation  as  transplantation  of  the  anterior  tem- 
poral artery. 


Fig.  82. — The  flap  on  the  neck  has  been  dissected  free  and  drawn  under  the  bridire 
of  skin  separating  its  base  from  the  defect  in  the  cheek.  The  artery  has 
been  partially  dissected.  Insert  shows  a  section  of  the  artery  with  ligation 
of  posterior  temporal  artery  when  necessary  to  secure  greater  length. 

The  cheek  is  prepared  for  the  new  flap  by  trimming 
away  the  scar  tissue  along  the  margins  of  the  defect  and 
by  undermining  the  skin  slightly.  The  position  of  the 
flap  to  be  transplanted  is  outlined  on  the  forehead  with 
the  point  of  a  knife,  going  as  near  to  the  hair  line  as  pos- 
sible. An  incision  is  made  over  the  region  of  the  an- 


290 


SURGERY    OF    THK    BLOOD-YESSELS. 


terior  temporal  artery,  extending  from  its  origin  to  the 
point  at  which  the  artery  enters  the  proposed  flap..  This 
incision  should  be  straight,  no  matter  what  the  course  of 
the  artery.  Great  care  is  taken  not  to  injure  the  artery 


Fig.  83. — The  flap  from  the  neck  has  been  sutured  in  position.  The  anterior  tem- 
poral artery  and  frontal  flap  have  been  freed,  and  are  ready  to  be  trans- 
planted. 

and  not  to  grasp  it  with  forceps.  It  can  be  easily  han- 
dled by  picking  up  the  tissue  around  it  with  delicate 
thumb  forceps.  Considerable  tissue  is  included  with  the 
artery  in  order  not  only  to  avoid  injury  to  the  artery, 
but  also  to  preserve  its  nerve  supply.  After  the  artery 
has  been  freed,  the  flap  is  cut  and  placed  in  position. 


TRANSPLANTATION    OF    ANTERIOR    TEMPORAL    ARTERY. 


This  gives  an  idea  where  the  artery  shall  lie  buried  (  K'm>. 
81,  82,  83  and  84).  The  flap  is  covered  with  cloths 
wrung  out  of  warm  salt  solution  and  an  inci>ion  for 
burying  the  artery  is  made  just  through  the  skin.  Tin- 


Fig.  84. — The  anterior  temporal  artery  with  the  frontal  flap  has  been  Irani-planted 
and  the  flap  sutured  in  position.  The  raw  surface  left  on  the  forehead  lias 
been  diminished  by  sutures  at  its  angles. 

margins  of  this  incision  are  undermined  freely,  but 
not  too  deeply.  In  this  way  the  branches  of  the  facial 
nerve  are  not  injured.  The  flap  is  placed  in  position 
and  fastened  with  a  few  sutures.  It  should  not  be  su- 
tured too  tightly,  because  the  flap  has  too  much  nutrition 
and  unless  there  is  some  point  where  the  excess  of  blood 


292  SURGERY    OF    THE    BLOOD-VESSELS. 

can  ooze  out  for  the  first  day  or  two,  the  tension  in  the 
flap  from  the  arterial  pressure  may  be  so  great  as  to 
cause  partial  necrosis.  A  few  stabs  in  the  flap  also  re- 
lieves the  venous  congestion.  This,  in  fact,  is  the  chief 
danger,  not  too  little  but  too  much  blood  supply.  If  it  is 
necessary  to  have  an  epithelial  lining,  a  flap  may  be 
turned  up  from  the  neck  and  sutured  with  the  skin  side 
toward  the  cavity  of  the  mouth  before  the  anterior  tem- 
poral artery  is  transplanted.  The  illustration  shows  the 
manner  of  doing  this.  Or,  if  the  defect  is  not  too  large, 
mucous  membrane  from  the  tongue,  as  suggested  by  Wil- 
lard  Bartlett,  can  be  used. 

By  the  second  day  the  flap  is  swollen  and  becomes  a 
dark  purple  color.  If  it  is  too  tense  every  few  hours  a 
sharp  knife  can  be  inserted  in  the  stab  wounds  or  along 
the  edges  of  the  flap  to  scrape  it  a  little  to  promote  bleed- 
ing and  relieve  the  tension.  After  a  week  the  swelling 
begins  to  disappear  and  the  new  venous  capillaries  drain 
away  the  blood.  The  efficiency  of  the  artery  can  be  dem- 
onstrated months  after  the  operation  by  pressing  upon 
it  and  noting  the  change  in  color  of  the  flap. 

In  two  cases  in  which  this  operation  was  done  the  ar- 
tery has  remained  patent  and  is  pulsating  several  months 
after  the  operation.  In  the  first  case,  all  of  the  flap 
took.  In  the  second,  a  middle  aged  woman  in  poor 
health,  about  two-thirds  of  the  flap  sloughed  away  on  ac- 
count of  excessive  passive  hyperemia. 

The  first  case,  Mr.  W.  H.  D.,  aged  22  years,  was  in- 
jured on  February  2,  1914,  by  a  shot  gun  while  trying  to 
quell  a  disturbance  among  the  laborers  of  a  mine  of 
which  he  was  superintendent.  The  gun  was  discharged 
at  short  range  and  blew  out  his  left  eye,  a  good  portion 
of  the  left  maxillary  bone,  and  the  septum  of  the  nose, 
together  with  the  soft  tissues  over  the  cheek.  The  ac- 


TRANSPLANTATION    OF    ANTERIOR    TEMPORAL    ARTEHV. 


Fig.    85. — Photograph   of   H.   D.    about   three   weeks   after   the   injury,    showing   a   large 
cavity    communicating    with    the    nasal    fossa. 


Fig.  86. — Photograph  of  H.  D.  three  weeks  after  operation  in  which  a  frontal  flap 
with  anterior  temporal  artery  attached  was  transplanted  to  cover  the  defect. 
Note  the  incision  for  dissecting  the  artery  and  also  incision  for  burying  it. 
The  artery  can  be  distinctly  felt  pulsating  in  its  new  bed. 


294 


SURGERY    OF    THE    BLOOD-VESSELS. 


companying  photograph  shows  his  condition  about  three 
weeks  after  the  injury.  A  large  cavity  was  left  con- 
nected with  the  nasal  fossa  (Fig.  85).  This  was  closed 
by  transplanting  from  the  forehead  a  flap  with  the 
anterior  temporal  artery.  The  technique  was  as  de- 
scribed above.  All  of  the  flap  took.  The  photograph 
taken  about  three  weeks  after  this  operation  shows  the 
line  of  incision  for  dissection  of  the  artery  and  also  the 
incision  under  which  the  artery  was  transplanted  (Fig. 
86). 

Mrs.  S.,  aged  47  years,  was  referred  to  the  author  for 
a  recurrent  cancer  of  the  cheek.     She  had  been  operated 


Fig  87. — Photograph  of  Mrs.  S.  about  thre.e  weeks  after  removal  of  recurrent 
cancer  of  the  cheek  with  Paquelifl  cautery.  The  tongue,  alveolar  process, 
and  some  denuded  bone  can  be  seen. 

upon  a  few  months  before  by  another  surgeon  and  as  re- 
currence was  prompt  and  the  glands  of  the  neck  were 
involved  the  prognosis  seemed  bad.  A  block  dissection 
was  first  done  on  the  upper  part  of  the  neck,  removing 
glands,  fat  and  fascia  in  one  mass.  The  cancer  in  the 
cheek,  which  was  about  an  inch  and  a  half  in  diameter, 


TRANSPLANTATION    OF    ANTERIOR    TEMPORAL    ARTKKY.        I'D.) 


Fig.  83. — Mrs.  S.  The  defect  in  the  cheek  practically  closed.  About  two-tliirds  of 
the  frontal  flap  sloughed  away,  but  enough  remained  to  close  tin-  upper 
portion  of  the  wound. 


Pig.    39. — Mrs.    S.,    with    eyes    closed,    showing    there    is    no    paralysis    of    am     branch 

of    the    facial    nerve. 


296  SURGERY    OF    THE    BLOOD-VESSELS. 

was  then  excised  with  a  Paquelin  cautery.  The  photo- 
graph shows  the  condition  about  ten  days  after  this  op- 
eration (Fig.  87).  The  defect  was,  of  course,  extensive 
and  the  deformity  great.  A  flap  of  skin  was  turned  un- 
der as  shown  in  the  accompanying  illustrations,  and  su- 
tured to  the  wound  with  the  skin  surface  inward.  The 
anterior  temporal  artery  with  a  flap  from  the  forehead 
was  then  transplanted  as  in  the  previous  case.  The  flap 
became  purple  and  tense,  but  on  scraping  its  edges  and 
letting  out  some  blood  its  color  would  again  become  nor- 
mal. The  growth  of  capillaries  was  poor,  and  about 
two-thirds  of  the  flap  sloughed  off  on  account  of  the  in- 
tense passive  hyperemia.  To  the  well  nourished  rem- 
nant, however,  flaps  from  neighboring  tissues  were  later 
attached  and  grew  satisfactorily.  The  photographs  show 
her  condition  before  and  after  the  plastic  operations 
(Figs.  87,  88,  and  89). 


NOTE. — Since  the  page  proof  has  come,  the  attention  of  the  author  has  been  called 
to  the  fact  that  Dr.  George  H.  Monks,  of  Boston,  trnnsplanted  the  anterior  tem- 
poral artery  with  an  attached  flap  to  restore  the  lower  evelid,  and  reported  the 
operation  in  the  Boston  Medical  and  Surgical  Journal  of  October  20,  1898.  The 
author  was  unaware  of  the  work  of  Dr.  Monks.  While  the  operation  described  in 
this  chapter  differs  in  several  details,  the  principle  involved  is  the  same,  and,  of 
course,  Dr.  Monks  is  entitled  to  priority. 


INDEX. 


INDEX. 


A 

Abbe,  Robert,  suturing  blood-vessels,  34 

Air  embolus,  187 

Allen,  infolding  the  aorta,  224 

Ariel's  ligation,  226,  227 

Anemia,  accommodation  for,  123 

Aneurism,  211 

Ariel's  ligation  for,  226,  227 

Antyllus'  ligation  for,  32,  226,  227 

arteriovenous,  245 

Brasdor's  ligation  for,  227,  228 

cause  of,  214 

cirsoid,  262 

excision  of,  42,  228,  234 

Hunter's  ligation  for,  226 

of  aorta,  235 
ligation  for,  236 
wiring,  221 

of  axjllary  artery,  239 

of  common  carotid,  237 

of  external  carotid,  237 

of  femoral  artery,  241 

of  iliac  artery,  240 

of  innominate,  237 

of  internal  carotid,  238 

of  popliteal  artery,  243 

of  subclavian  artery,  239 

Purmann's  ligation  for,  228 

symptoms  and  signs  of,  215 

treatment  of.  219 

treatment  of,  gelatin  in,  219 

Wardrop's  ligation  for,  227,  228 
Aneurismorrhaphy,  229 
Angioma,  255 

Antyllus'  ligation  for  aneurism,  32,  226,  227 
Aorta,  aneurism  of,  235 

constriction  of,  224,  237 

treatment  of  aneurism  of,  219 
Arteries,  healing  of,  24 

indications  for  suturing,  29 

instruments  for  suturing,  50 

principles  of  suturing,  47 

structure  of,  17 

wounds  of,  78 
Arteriovenous  aneurism,  245 

treatment  of,  249 

Artery,  anterior  temporal,  transplantation  of,  286 
Axillary  artery,  aneurism  of,  239 

299 


300  INDEX. 


B 

Bernheim,  lateral  anastomosis  of  blood-vessels,  82 

method  of  transfusion,  104,  105 

on  Eck  fistula,  82 
Bladder,  hemorrhage  from,  162 
Blood,  clotting  of,  46,   176 

transfusion  of,  see  transfusion 
Blood-vessels,  17 

healing  of,  24 

histology  of,  17 

history  of  surgery  of,  31 

indications  for  suturing,  29 

lateral  anastomosis  of,  80 

principles  of  suturing,  47 

structure  of,  17 

suturing  wounds  of,  78 

technique  of  suturing,  50 

tumors  of,  255 
Bowel,  gangrene  of,  203 

hemorrhage  from,  159 

resection  of,  204 

transplantation  of,  209,  210 
Brasdor's  ligation  for  aneurism,  227,  228 
Brewer,  transfusion  of  blood,  102 
By  ford,  accommodation  anemia,  123 


Capillaries,  structure  of,  23 
Carrel,  Eck  fistula,  83 

suturing  blood-vessels,  37,  38 
Carotid  arteries,  aneurism  of,  237 
Circulation,  reversal  of,  81 
Cirsoid  aneurism,  262 
Common  carotid,  aneurism  of,  237 
Crile,  hemorrhage  and  shock,  137 

transfusion  of  blood,  99,  101 

D 

Donor  in  transfusion,  121 
Dorfler,  suturing  blood-vessels,  35 
Dorrance,  suturing  blood-vessels,  40 
Duodenal  ulcer,  hemorrhage  from,  158 

E 

Eck  fistula,  80 

Elsberg,  method  of  transfusion,  104,  106 

Embolism,  185 

of  mesenteric  arteries,  203 

pulmonary,  194 
Embolus,  185 

air,  187 

"crossed,"  187 

fat,  192 

"paradoxical,"  187 

pulmonary,  194 

Trendelen burg's  operation  for  pulmonary,  196 
Endo-aneurismorrhaphy,  229 
External  carotid,  aneurism  of,  237 


INDEX.  ;joi 


Fat  embolus,  192 
Femoral  artery,  aneurism  of,  241 
Finney,  wiring  aneurism,  221 
Fishbein,  test  for  liemolysis,  125 


G 


Gastric  ulcer,  hemorrhage  from,  157 
Guthrie,  suturing  blood-vessels,  48,  49 

H 

Halstead,  reversal  of  circulation,  80 

metal  band,  224,  237 
Hemolysis  in  transfusion,  125 

in  transfusion,  test  for,  125 
Hemophilia,  169 

treatment  of,   171 
Hemorrhage,  135 

during  operation,  control  of,  149 

from  bladder,   162 

from  brain,  153 

from  bowel,  159 

from  chest,  156 

from  extremities,  167 

from  face,  153 

from  gastric  or  duodenal  ulcer,  157 

from  jaundice,  175 

from  kidneys,   161 

from  liver,   157,   160 

from  nose,  153 

from  prostatectomy,  151,  162 

from  rectum,   160 

from  scalp,  152 

from  stomach,   157 

from  urethra,   165 

from  uterus,  165 

Momburg's  tourniquet  in,  141 

pathologic,  169 

symptoms  of,  135 

shock  and,  136 

treatment  of,  137 
Hemorrhoids,  274 

operation  for,  under  local  anesthesia,  285 

treatment  of,  276,  277 

treatment  of,  by  clamp  and  cautery,  281 

treatment  of,  by  excision,  280 

treatment  of,  by  injection,  278 

treatment  of,  by  ligature,  280 
History  of  blood-vessel  surgery,  31 
Horsley,  J.  S.,  healing  of  blood-vessels,  26 

lateral  anastomosis  of  blood-vessels,  86 

report  of  cases  of  transfusion,  130 

resection  of  intestine,  204 

substituting  a  tube  for  a  segment  of  an  artery,  71 

suturing  blood-vessels,  54 

transfusion  of  blood,  116,  118 

transplantation  of  anterior  temporal  artery,  286 


30'2  INDEX. 

transplantation  of  intestine,  21  Hi,  ^Kt 
Horsley,  Victor,  bone  wax.  14.5 
Hunter,  -John,  ligation   for  aneurism.  22i> 
Hypodermoclysis,   14U 


Iliac  arteries,  aneurism  of,  240 
Infusion,   intravenous,   14(j 
Innominate  artery,  aneurism  of,  237 
Internal  carotid  artery,  aneurism  of.  238 
Intestine,  gangrene  of,  203 

resection  of,  204 

transplantation  of,  209,  210 

K 

Kidneys,  hemorrhage  from,  161 
Kimpton,  method  of  transfusion,   109 

L 

Lespinasse,  suturing  blood-vessels,  41 
Lexer,  excision  of  aneurism,  42 

transplantation  of  saphenous  vein,  42 
Lindeman,  transfusion  of  blood,   111 
Liver,  hemorrhage  from,  157 
Locke's  solution,  147 

M 

Magnesium  rings  in  blood-vessel  surgery,  3(3,  41 
Matas,  aneurisinorrhapliy,  229 

infolding  the  aorta,  224 

metal  band,  224 

Mayo,  C.  H.,  treatment  of  varicose  veins,  268 
Mayo,  W.  J.,  hemorrhage  after  nephrectomy,  139 
McGrath,  transfusion  of  blood,  113 
Melena  neonatorum,  169,  175 
Mesenteric  blood-vessels,  occlusion  of,  203 
Momburg,  tourniquet,  141 

Moore-Corradi  method  of  wiring  aneurisms,  221 
Murphy,  John  B.,  first  suture  of  blood-vessels,  34 

reversal  of  circulation,  82 


X 


Xevus,  255 

Wyeth's  treatment  of,  260 
Xose-bleeding,   153 


Pare,  Ambroise,  use  of  ligature  by,  32 

Payr,  magnesium  rings,  36 

Piles,  see  hemorrhoids 

Popliteal  artery,  aneurism  of,  243 

Prostatectomy,  hemorrhage  from,  151,  162 

Prothrombin,  46 


IXDEX. 

Purmann's  ligature  for  aneurism,  228 
Pulmonary  embolism,   194 

operation  for,   196 
Purpura,  174 

E 

Recipient  in  transfusion,   123 
Rectum,  hemorrhage  from,   160 
Reversal  of  the  circulation,  81 
Ringer's  solution,  147 

S 

Smith,  E.  A.,  healing  of  blood-vessels,  27 

suturing  blood-vessels,  41 
Stomach,  hemorrhage  from,  157 
Stone,  lateral  anastomosis  of  blood-vessels,  82 
Subclavian  artery,  aneurism  of,  239 
Sweet,  Eck  fistula,  83 

T 

Temporal  artery,  transplantation  of,  286 
Thomaselli,  healing  of  blood-vessels,  27 
Thrombogen,  46 
Thrombokinase,  46 
Thrombosis,  46,   176 

of  mesenteric  blood-vessels,  203 

septic,  184 
Tourniquet,  140,  167 

of  Momburg,  141 
Transfusion  of  blood,  concerning  the  donor  in,  121 

concerning  the  recipient  in,   123 

dangers  of,   119 

defibr mated  blood  in,  98,  99,  115 

hemolysis  in,  125 

history  of,  95 

indications  for,  128 

method  of  Bernheim,  104,  105 

method  of  Brewer,  102 

method  of  Crile,  99,  101 

method  of  Elsberg,  104,  106 

method  of  Horsley,  116,  118 

method  of  Kimpton  and  Brown,  109 

method  of  Lindeman,   111 

method  of  McGrath,    113 

operating  room  technique,   127 

use  of  quill  in,  96 
Transplantation  of  anterior  temporal  artery,  280 

of  organs,  29 

of  saphenous  vein,  42,  69 

of  veins,  69 

Trendelenburg,  operation  for  pulmonary  embolus,  196 
Tube,  suturing  in,  for.  defect  in  artery,  69,  71 
Tumors  of  blood-vessels,  255 

U 
Ulcer,  gastric  or  duodenal,  hemorrhage  from,  157 


304  INDEX. 

Urethra,  hemorrhage  from,  165 
Uterus,  hemorrhage  from,  165 


Varices,  264 
Varicocele,  270 

treatment  of,  271 
Varicose  veins,  264 

treatment  of,  267 
Veins,  structure  of,  22 

transplantation  of,  42,  69 

varicose,  264 


W 


Wardrop's  ligation  for  aneurism,  227,  228 

Watts,  healing  of  blood-vessels,  27 

Welch,  thrombosis  and  embolism,  186 

Williams,  E.  G.,  gelatin  in  treatment  of  aneurism,  219 

Wounds  of  blood-vessels,  suturing,  78 

Wveth's  treatment  of  nevi,  260 


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